Well, okay, I didn't literally ride on any rollercoasters, at least not the sort that you find at the PNE and suburban carnivals. But some of the minibuses (matatus) that I ventured forth in across the Ugandan countryside perhaps shared some characteristics with the traditional rollercoaster. Sure, they look different, they only have four wheels, they don't do loop-de-loops (if you're lucky) but they can very effectively evoke that freaky feeling in the pit of your stomach that rollercoasters tend to elicit when you're hanging suspended upside down forty feet above the ground. The minibuses that transport people (and goods, don't forget the goods) around Uganda are designed to carry 14 passengers. In Kampala, that's generally the case - 14 people plus the driver. Not too squishy. Room to reposition your legs, ensure some blood flow to the extremities, shift your bum when it starts to go numb. The countryside is a different story. When it comes to matatus, more people means more money for the driver and conductor. And often the matatu you're in is the only one that will be through that area for a number of hours. The local people who live in that area have no other means of transportation so the conductor does his best to get everyone in who needs a ride. You quickly learn that to get anywhere in a rural region of Uganda, you'd best be prepared to get cozy with your seat mates. I was commonly in matatus with 22-24 people, plus livestock (chickens, no goats), produce (pineapples, matoke, onions, jackfruit), and belongings. Some of the buses have racks on the top for the myriad mattresses, bags, and shopping. Some don't. I spoke with a traveller who had been in a matatu with 32 people. This basically means that a third of the passengers are sitting on top of the other passengers. Fun way to meet new people. Generally these hardy vehicles are travelling on dirt roads or paved roads that haven't seen new asphalt for quite some time - lots of potholes, lots of washouts. The terrain definitely contributes to the sense of riding a rollercoaster, as does the somewhat erratic driving behaviours of many matatu drivers. But you know, pretty cheap carnival ride, compared to what you'll pay at the PNE. Once I managed to silence (or at least generally ignore) that little voice in my head making comments like "no seatbelts", "trapped inside", "when were the brakes last serviced?", I found myself thoroughly enjoying the chaotic nature of transportation in Uganda. A comraderie seems to develop among the passengers as we shift and shuffle to take on yet another person, children on laps, adults sitting on one bum-cheek, chickens squawking from beneath our feet.
I'm on another sort of rollercoaster ride now, that of readjusting to life at home. This ride is more emotional than physical, more theoretical than tangible. I arrived home in Victoria on August 6, having flown into Vancouver International Airport and then hopped aboard BC Ferries for the ever-beautiful crossing to Swartz Bay, where I was met by my lovely Mom. I am happy to be home. I'm so pleased to have much of the month of August to readjust to life in Canada before starting my fourth and final year of midwifery school. But I am certainly feeling the confusion and imbalance that comes with shift of place, shift of reality, shift of economics. Our privilege and wealth (on a general scale, as a society) is at times overwhelming, at times comforting. It's going to take some time to find my balance.
There's more to come.
Heather
Friday, August 10, 2007
Wednesday, August 8, 2007
Some photos at last!
A Ugandan mama and baby of the pachaderm tribe in Queen Elizabeth National Park.
Signpost at the entrance to the Masaka Hospital
Entrance way into the maternity ward at Masaka Hospital
One of the four beds in the delivery room
This is me with one of our mamas in Masaka - this baby was the woman's fifth. We had expected a fast pushing stage because she was a gravida 5, but the baby's head was asynclitic - he was born with a lot of moulding on the right parietal bone. Came through in a very difficult position. What a strong mama and baby!
The view from our hostel in Kampala - looking out over the slum/shanty town towards Mulago Hospital. The heavy pollution is standard in Kampala. Most of the vehicles run on diesel, and it's common to see heavy black exhaust pouring out of the tailpipes of vans, trucks, and boda boda (motorcycles).
Anne-Marie on our walk home from the hospital. Coffin makers are a common sight in Uganda - there's a steady demand for their merchandise.
Sarah, me, and Florence. Sarah is the Senior In-Charge midwife at Upper Mulago and was incredibly welcoming and encouraging. Florence was one of the regular midwives on the ward.
Boda boda drivers on Kampala streets. While we were wearing light t-shirts, they were dressed in down jackets. These motorcycle taxis are a common mode of transport in the city and the fastest way to get around during "jam" (daily morning and evening traffic snarls) because they never hesitate to weave their way through the bigger vehicles on the road.
Selling matoke at Owina Market in Kampala. Matoke, made from these green plantain, is the staple starch food in Uganda.
Women selling spices at Owina Market.
You just can't imagine how excited I was to see giraffes, up close. They're so amazingly cool! This was in Murchison Falls National Park.
Saturday, July 14, 2007
Farewell Mulago
It's Saturday morning, the sun is finally making an appearance, the grey clouds that dropped some rain on us earlier having headed off for other parts. Anne-Marie and I are spending the weekend in Kampala, each of us with various errands to complete, before we head our separate ways for our remaining time in Uganda. Anne-Marie is taking off for the Seese Islands in Lake Victoria and I'm going to go to the southwest of the country to spend some time at Lake Bunyonyi. We are both looking forward to some time spent relaxing, reading, thinking, sleeping, and exploring Uganda.
Our final two days on Ward 14 were challenging and rewarding, with some joyful and difficult outcomes. On Thursday, a baby died. Most likely from meconium aspiration. We weren't at the birth but had been attending the mother during labour. I had ruptured her membranes when she was about 9 cm dilated to find thick meconium in the fluid. (Meconium is the baby's poop - sometimes babes poop before they're born. It can at times indicate fetal distress and thick meconium can be a warning sign that the babe will have difficulty breathing after birth.) The babe's heart rate was incredibly normal and reassuring throughout labour - I heard no decels. I don't know what resuscitation steps were taken at the birth, but they don't have the capacity to intubate babies on Ward 14 so most likely he was suctioned and then ventilated. When we saw him, he was under the warming lamp, an oxygen tube in his nose, with poor tone, waiting for transfer to New Mulago. According to the midwife who took him down to the special care nursery, the doctor there "did everything" but he still died. We were surprised. Though he didn't look well when we saw him, he was breathing and his colour wasn't terrible. I've been thinking a lot about this loss, for a few reasons. We've caught a lot of babes here with meconium stained fluid. They've all done well, often with no more resuscitation needed than routine stimulation after birth. I think I had let my guard down regarding the potential seriousness of meconium. I am reflecting on this birth, wondering if when the thick meconium was noted, we could have transferred the mother to New Mulago before the babe was born. Would she have received better care there? Would a pediatrician have seen him sooner? Would they have intubated him shortly after birth, suctioned the meconium from his lungs? I don't know. New Mulago is an insanely busy ward. There's no guarantee that he would have received pediatric care there any sooner than he did being born on Ward 14 and then transferred down. So I think I'm feeling some remorse and responsibility for this babe's death, wishing that I'd responded to the meconium with more urgency when it was first noted. I can't know whether it would have changed the outcome, but I can't help wondering.
Late Thursday afternoon I attended an 18 year old woman having her first baby. Her name was Rose, a woman who could have been 15 or 16 in looks and demeanor. She had a slow second stage, pushing on her back, on her knees, in a squat, on her side. She pushed out her babe, a normal delivery, though she had a second degree tear. Well, every outcome is a learning opportunity, so I got to suture, a skill that I still don't feel really confident with. And you know, it went well. It was a straightforward tear and I think I sutured well. Continuous sutures for the muscle and then subcuticular stitches for the perineum.
Apparently the sun that I mentioned at the beginning of this post high-tailed it out of here in the face of an approaching rainstorm. The water is pelting down from the sky outside, it's dark and wet and windy and I'm glad that I haven't yet left for my journey down town.
Yesterday we spent our final day on Ward 14. We took in some cake and cookies to share with the midwives who have been so generous in allowing us to catch babies on their turf. The morning was busy - three babies caught in the first hour and a half. As we walked on to the ward, one of the midwives called to us, saying "come and help, there's three babies coming!" Anne-Marie caught two - one multigravida, one primigravida. Both straightforward, uncomplicated deliveries. I caught one - the woman's third babe. There was a double nuchal cord (meaning the cord was wrapped around the babe's neck twice), which I was unable to unwrap before the babe was born. He ended up somersaulting out, sort of. The woman had a small tear, not too bad but given that she was a multip, probably heading home to chase after her other babes the next day, I thought that suturing it would probably help it heal faster. She was reluctant. I wonder whether she'd been sutured before without any anaesthetic? It's pretty common here for midwives to suture a second degree tear using no lidocaine. And they wonder why women are "uncooperative", and "non-compliant"?! Sarah, the in-charge midwife, told us that in Uganda, there's an erroneous belief that using anaesthetic when suturing will prevent the tear from healing as well. After repeated assurances that I would use freezing, she agreed to the suturing. It was straighforward and didn't take too long.
After lunch, we had two final births. Both births happened in the same room, the women separated by a pink curtain. Anne-Marie attended one birth, and I the other. These births, somehow they summed up what we've learned and taught while here in Uganda. Anne-Marie attended Cate, a woman in her fourth pregnancy, 26 or so weeks along, who arrived at the ward crying out that her baby was coming. She was escorted into the assessment room, where Anne-Marie tried to find the fetal heart but wasn't sure that she could hear it. The babe was definitely coming - in fact coming breech. It was clear as soon as the body was out to the umbilicus that the babe was already dead. There was no pulse in the umbilical cord. Anne-Marie assisted the babe's body out with the breech manoeuvres; the legs and arms came easily. But the woman's cervix was not yet dilated enough to allow the head to come. Her contractions stalled and the babe's head was trapped behind a tight cervix. In some ways, it was a blessing that the babe had already died, as I think our adrenaline and anxiety would have been much higher if this live baby's head was trapped. It most likely would have died anyway as we had to put in an IV, hang normal saline with oxytocin to stimulate more contractions, and dilate the cervix enough for the head to be born. It took about 15 minutes for the mom to start getting contractions again and with a strong urge to push, Anne-Marie was able to assist the birth of the head. Her third stage was uncomplicated, the placenta came out complete, and she had little bleeding after the birth. Perhaps the saddest part of this birth was the mother's question, after the babe was born, "is my baby okay?" Anne-Marie had tried to communicate during the delivery that it was too early for the babe to be born and that it had already died but perhaps the mama had been too distressed to understand what Anne-Marie was saying. Anne-Marie handled this birth with such professionalism, such grace and skill, it was heartwarming, despite the sad outcome, to watch her attend this woman and comfort her afterwards.
On the other side of the pink curtain, I was standing with a primigravida, 20 year old Lilian, who was pushing out her baby. She had a beautiful 45 minute 2nd stage, a slow crowning of the head, an uncomplicated delivery of her baby girl. The wee one was a little slow to start but she came around with stimulation, coughing out the mucus that had been plugging up her airway. Lilian's perineum was completely intact, not a graze. What dichotomies, these two births. On one hand, a complicated breech delivery of a preterm stillborn infant, managed calmly, with skill. On the other hand, a new mother supported respectfully during her normal delivery, not cut, not berated to "push push push", her wee one gently welcomed into the world. I feel like these two births epitomize much of what we've learned and shared while we've been here. We've seen and begun to manage complex cases, births that we would rarely or never attend in Canada. We've also brought a different way of managing second stages to the midwives here, showed them that births can be slow and safe, that episiotomies are rarely indicated, that first-time mothers can come through birth without injury to their bodies. It was an emotional end to our last day. It felt like an appropriate ending.
That's enough writing for today. I don't know when I'll next have access to internet, but I'm sure there will be future posts to 'Birth in Uganda' at some point as I mull over all that I've seen and done while here. I'm missing home and looking forward to sharing in person with my friends and family once I'm back.
Love and light,
Heather
Our final two days on Ward 14 were challenging and rewarding, with some joyful and difficult outcomes. On Thursday, a baby died. Most likely from meconium aspiration. We weren't at the birth but had been attending the mother during labour. I had ruptured her membranes when she was about 9 cm dilated to find thick meconium in the fluid. (Meconium is the baby's poop - sometimes babes poop before they're born. It can at times indicate fetal distress and thick meconium can be a warning sign that the babe will have difficulty breathing after birth.) The babe's heart rate was incredibly normal and reassuring throughout labour - I heard no decels. I don't know what resuscitation steps were taken at the birth, but they don't have the capacity to intubate babies on Ward 14 so most likely he was suctioned and then ventilated. When we saw him, he was under the warming lamp, an oxygen tube in his nose, with poor tone, waiting for transfer to New Mulago. According to the midwife who took him down to the special care nursery, the doctor there "did everything" but he still died. We were surprised. Though he didn't look well when we saw him, he was breathing and his colour wasn't terrible. I've been thinking a lot about this loss, for a few reasons. We've caught a lot of babes here with meconium stained fluid. They've all done well, often with no more resuscitation needed than routine stimulation after birth. I think I had let my guard down regarding the potential seriousness of meconium. I am reflecting on this birth, wondering if when the thick meconium was noted, we could have transferred the mother to New Mulago before the babe was born. Would she have received better care there? Would a pediatrician have seen him sooner? Would they have intubated him shortly after birth, suctioned the meconium from his lungs? I don't know. New Mulago is an insanely busy ward. There's no guarantee that he would have received pediatric care there any sooner than he did being born on Ward 14 and then transferred down. So I think I'm feeling some remorse and responsibility for this babe's death, wishing that I'd responded to the meconium with more urgency when it was first noted. I can't know whether it would have changed the outcome, but I can't help wondering.
Late Thursday afternoon I attended an 18 year old woman having her first baby. Her name was Rose, a woman who could have been 15 or 16 in looks and demeanor. She had a slow second stage, pushing on her back, on her knees, in a squat, on her side. She pushed out her babe, a normal delivery, though she had a second degree tear. Well, every outcome is a learning opportunity, so I got to suture, a skill that I still don't feel really confident with. And you know, it went well. It was a straightforward tear and I think I sutured well. Continuous sutures for the muscle and then subcuticular stitches for the perineum.
Apparently the sun that I mentioned at the beginning of this post high-tailed it out of here in the face of an approaching rainstorm. The water is pelting down from the sky outside, it's dark and wet and windy and I'm glad that I haven't yet left for my journey down town.
Yesterday we spent our final day on Ward 14. We took in some cake and cookies to share with the midwives who have been so generous in allowing us to catch babies on their turf. The morning was busy - three babies caught in the first hour and a half. As we walked on to the ward, one of the midwives called to us, saying "come and help, there's three babies coming!" Anne-Marie caught two - one multigravida, one primigravida. Both straightforward, uncomplicated deliveries. I caught one - the woman's third babe. There was a double nuchal cord (meaning the cord was wrapped around the babe's neck twice), which I was unable to unwrap before the babe was born. He ended up somersaulting out, sort of. The woman had a small tear, not too bad but given that she was a multip, probably heading home to chase after her other babes the next day, I thought that suturing it would probably help it heal faster. She was reluctant. I wonder whether she'd been sutured before without any anaesthetic? It's pretty common here for midwives to suture a second degree tear using no lidocaine. And they wonder why women are "uncooperative", and "non-compliant"?! Sarah, the in-charge midwife, told us that in Uganda, there's an erroneous belief that using anaesthetic when suturing will prevent the tear from healing as well. After repeated assurances that I would use freezing, she agreed to the suturing. It was straighforward and didn't take too long.
After lunch, we had two final births. Both births happened in the same room, the women separated by a pink curtain. Anne-Marie attended one birth, and I the other. These births, somehow they summed up what we've learned and taught while here in Uganda. Anne-Marie attended Cate, a woman in her fourth pregnancy, 26 or so weeks along, who arrived at the ward crying out that her baby was coming. She was escorted into the assessment room, where Anne-Marie tried to find the fetal heart but wasn't sure that she could hear it. The babe was definitely coming - in fact coming breech. It was clear as soon as the body was out to the umbilicus that the babe was already dead. There was no pulse in the umbilical cord. Anne-Marie assisted the babe's body out with the breech manoeuvres; the legs and arms came easily. But the woman's cervix was not yet dilated enough to allow the head to come. Her contractions stalled and the babe's head was trapped behind a tight cervix. In some ways, it was a blessing that the babe had already died, as I think our adrenaline and anxiety would have been much higher if this live baby's head was trapped. It most likely would have died anyway as we had to put in an IV, hang normal saline with oxytocin to stimulate more contractions, and dilate the cervix enough for the head to be born. It took about 15 minutes for the mom to start getting contractions again and with a strong urge to push, Anne-Marie was able to assist the birth of the head. Her third stage was uncomplicated, the placenta came out complete, and she had little bleeding after the birth. Perhaps the saddest part of this birth was the mother's question, after the babe was born, "is my baby okay?" Anne-Marie had tried to communicate during the delivery that it was too early for the babe to be born and that it had already died but perhaps the mama had been too distressed to understand what Anne-Marie was saying. Anne-Marie handled this birth with such professionalism, such grace and skill, it was heartwarming, despite the sad outcome, to watch her attend this woman and comfort her afterwards.
On the other side of the pink curtain, I was standing with a primigravida, 20 year old Lilian, who was pushing out her baby. She had a beautiful 45 minute 2nd stage, a slow crowning of the head, an uncomplicated delivery of her baby girl. The wee one was a little slow to start but she came around with stimulation, coughing out the mucus that had been plugging up her airway. Lilian's perineum was completely intact, not a graze. What dichotomies, these two births. On one hand, a complicated breech delivery of a preterm stillborn infant, managed calmly, with skill. On the other hand, a new mother supported respectfully during her normal delivery, not cut, not berated to "push push push", her wee one gently welcomed into the world. I feel like these two births epitomize much of what we've learned and shared while we've been here. We've seen and begun to manage complex cases, births that we would rarely or never attend in Canada. We've also brought a different way of managing second stages to the midwives here, showed them that births can be slow and safe, that episiotomies are rarely indicated, that first-time mothers can come through birth without injury to their bodies. It was an emotional end to our last day. It felt like an appropriate ending.
That's enough writing for today. I don't know when I'll next have access to internet, but I'm sure there will be future posts to 'Birth in Uganda' at some point as I mull over all that I've seen and done while here. I'm missing home and looking forward to sharing in person with my friends and family once I'm back.
Love and light,
Heather
Wednesday, July 11, 2007
Soon to say farewell
It's a Wednesday evening, our last week working as midwives here in Kampala, and I think Anne-Marie and I are both feeling ready for a break. I am feeling the need for time to integrate, to mull, to write, to hunker down and process all that we've seen and learned in our 5 weeks here in Uganda. Being in the midst of it, up to our elbows in amniotic fluid, meconium, blood, and feces every day, I've found it hard to really contemplate how maternity care in Uganda impacts women, babes, and the people who work as midwives, doctors, and nurses in this system. You know, it's been very easy to focus on the ways that maternity care here could/should improve, but we were also acknowledging today that here in Kampala, there are many things that are being done well. Almost all the women we see have been for at least one antenatal appointment, where they've been screened for HIV and determined to be high or low risk. If they are HIV positive, they have access to treatment. If they're considered low risk, they are sent to Ward 14, Upper Mulago, to have their babies. And this screening seems to be quite accurate. In our week and a half working in Ward 14, we've yet to see a woman with gestational hypertension present in pregnancy, twins, breech, or any other complex care needs come through our door. Those women have been screened out and sent to the high risk ward at New Mulago. So almost every birth we've seen on Ward 14 has been straight-forward, normal - no postpartum hemorrhage, no seizures, no malpresentations. So that's something that here in Kampala, seems to be working relatively well.
The question is, what sort of care do the high-risk women get at New Mulago? We occasionally walk past the high risk ward and see the women lining the halls, throngs of people outside the entrance, many of them attendants for the overwhelming numbers of women inside. Today we thought we would spend an afternoon on the high risk ward to try and get some resuscitation experience as we haven't had much opportunity to resuscitate babies on Ward 14. There is a resuscitation room where babes are brought after birth if they are having trouble getting started. Cathy had suggested, on taking her leave from Uganda, that if we were to return to the high risk ward we should restrict ourselves to doing resuscitation only, as you never know what you might get sucked into on that ward. The need is so great, the staff obviously too few, and many of the cases fairly complex. There was no guarantee that if we were suddenly faced with a difficult case that we would be able to find someone to back us up. So after checking in with the "in-charge", we ensconsed ourselves in the resus room, with a copy of the ALARM manual (emergency obstetrics manual) to pass the time, and waited for a baby. It didn't take too long. Shortly after our arrival, a babe was deposited on the vinyl-covered pad by a nursing student who quickly took her leave. We were left to assess this wee boy. He was limp, not breathing, was dusky, meconium was obviously present, and he had a strange smell about him. The smell reminded me of the smell of the macerated still-born babe I caught in Masaka - a smell that isn't healthy, shouldn't be associated with a normal birth. But this babe was alive, with a heart rate of 110 - he needed a little jumpstart. So we ventilated him and his heart rate remained stable, but he wasn't really making any effort to breathe himself, so we carried on with ventilation - "breathe little baby, breathe little baby" - the mantra of Neonatal Resuscitation running through my head. Eventually he started making some breathing efforts but he was still so limp and sounded really mucousy. The wall suction didn't seem to be working so I used a bulb syringe (never seen in Canada any more but the main resuscitation aid here in Uganda) to try to clean some of the muck out of his mouth and nose. Finally Anne-Marie got the wall suction working, but there was no flexible tubing to attach to it in order to suction out his pharynx so we did the best we could with the rigid plastic attachment. Looking back on it, perhaps we should have suctioned his mouth before starting ventilation, but I think if he'd started crying or coughing or sneezing with the ventilation, he would have cleared his own lungs. I certainly felt my lack of experience during this resus but he did eventually come around, and after about 2 minutes of ventilation, plus the suction and some more stimulation, his tone was better, his heart rate was 130, and he was breathing on his own. But I'd give that baby an apgar of 7 at 5 minutes. But what about the smell that I mentioned? I think his mother was probably infected and that babe most likely should have IV antibiotics.
As we were trying to arrange for him to go to the special care nursery for further monitoring, we discovered that his mother (and the midwife and students attending her) were waiting for his twin to be born. It's so hard to describe the chaos of New Mulago. The attending midwife comes in, takes a quick look at the baby, says he's fine and doesn't need to go to special care. Our comments about infection, ongoing gurgly lungs, seem to fall on deaf ears as she heads back to attend to the mother. We're told to wrap the babe up in another cloth and leave him in a cot. As this is transpiring, Anne-Marie hears a woman calling for a midwife. She walks by the cubicle where the woman is labouring. The woman is obviously pushing. Then the head is visible. There's no midwife in sight. Anne-Marie calls for an attendant. No one comes. We weren't going to catch babies at New Mulago but if Anne-Marie doesn't put on her gloves and catch, this babe will have no hands to receive it as it makes its entrance. So Anne-Marie catches. And the woman has a postpartum hemorrhage. And we're not sure if the blood is coming from the uterus because it's well contracted but the blood keeps gushing out. She definitely has a second degree perineal tear but that's not where the blood is coming from. Cervical tear? By this time, there are a couple of interns also on the scene, trying to figure out where this blood is coming from. We hang normal saline with oxytocin. The blood slows but gushes whenever you massage her uterus. The interns don't think there's a cervical tear and in the end decide it was uterine blood. It seems to ease after 15 minutes or so and we leave the interns to repair her tear. We head back to the resuscitation room.
In the end, we didn't have any more resuscitations but Anne-Marie catches yet another baby due to absent midwives. How strange, that in a second stage room, with five beds, each containing a labouring mother, there is no midwife. How can that be? Are they so short-staffed? Are they ignoring the calls of help from mothers? Are they so over-worked, underpaid, and apathetic that their work no longer holds any reward or joy? I could see it happening but it still just seems so bizarre that women are left to labour and birth without the benefit of caregivers.
As for the wee babe we resuscitated, well, his mom was sent off for a C-section for delivery of the second twin. Apparently the second was presenting his face (deflexed head) and not coming down so she went for cesar (as they're called here). I doubt that he'll get antibiotics but I hope that someone assessed him after we left to make sure he was still holding his own.
Two days to go.
Heather
The question is, what sort of care do the high-risk women get at New Mulago? We occasionally walk past the high risk ward and see the women lining the halls, throngs of people outside the entrance, many of them attendants for the overwhelming numbers of women inside. Today we thought we would spend an afternoon on the high risk ward to try and get some resuscitation experience as we haven't had much opportunity to resuscitate babies on Ward 14. There is a resuscitation room where babes are brought after birth if they are having trouble getting started. Cathy had suggested, on taking her leave from Uganda, that if we were to return to the high risk ward we should restrict ourselves to doing resuscitation only, as you never know what you might get sucked into on that ward. The need is so great, the staff obviously too few, and many of the cases fairly complex. There was no guarantee that if we were suddenly faced with a difficult case that we would be able to find someone to back us up. So after checking in with the "in-charge", we ensconsed ourselves in the resus room, with a copy of the ALARM manual (emergency obstetrics manual) to pass the time, and waited for a baby. It didn't take too long. Shortly after our arrival, a babe was deposited on the vinyl-covered pad by a nursing student who quickly took her leave. We were left to assess this wee boy. He was limp, not breathing, was dusky, meconium was obviously present, and he had a strange smell about him. The smell reminded me of the smell of the macerated still-born babe I caught in Masaka - a smell that isn't healthy, shouldn't be associated with a normal birth. But this babe was alive, with a heart rate of 110 - he needed a little jumpstart. So we ventilated him and his heart rate remained stable, but he wasn't really making any effort to breathe himself, so we carried on with ventilation - "breathe little baby, breathe little baby" - the mantra of Neonatal Resuscitation running through my head. Eventually he started making some breathing efforts but he was still so limp and sounded really mucousy. The wall suction didn't seem to be working so I used a bulb syringe (never seen in Canada any more but the main resuscitation aid here in Uganda) to try to clean some of the muck out of his mouth and nose. Finally Anne-Marie got the wall suction working, but there was no flexible tubing to attach to it in order to suction out his pharynx so we did the best we could with the rigid plastic attachment. Looking back on it, perhaps we should have suctioned his mouth before starting ventilation, but I think if he'd started crying or coughing or sneezing with the ventilation, he would have cleared his own lungs. I certainly felt my lack of experience during this resus but he did eventually come around, and after about 2 minutes of ventilation, plus the suction and some more stimulation, his tone was better, his heart rate was 130, and he was breathing on his own. But I'd give that baby an apgar of 7 at 5 minutes. But what about the smell that I mentioned? I think his mother was probably infected and that babe most likely should have IV antibiotics.
As we were trying to arrange for him to go to the special care nursery for further monitoring, we discovered that his mother (and the midwife and students attending her) were waiting for his twin to be born. It's so hard to describe the chaos of New Mulago. The attending midwife comes in, takes a quick look at the baby, says he's fine and doesn't need to go to special care. Our comments about infection, ongoing gurgly lungs, seem to fall on deaf ears as she heads back to attend to the mother. We're told to wrap the babe up in another cloth and leave him in a cot. As this is transpiring, Anne-Marie hears a woman calling for a midwife. She walks by the cubicle where the woman is labouring. The woman is obviously pushing. Then the head is visible. There's no midwife in sight. Anne-Marie calls for an attendant. No one comes. We weren't going to catch babies at New Mulago but if Anne-Marie doesn't put on her gloves and catch, this babe will have no hands to receive it as it makes its entrance. So Anne-Marie catches. And the woman has a postpartum hemorrhage. And we're not sure if the blood is coming from the uterus because it's well contracted but the blood keeps gushing out. She definitely has a second degree perineal tear but that's not where the blood is coming from. Cervical tear? By this time, there are a couple of interns also on the scene, trying to figure out where this blood is coming from. We hang normal saline with oxytocin. The blood slows but gushes whenever you massage her uterus. The interns don't think there's a cervical tear and in the end decide it was uterine blood. It seems to ease after 15 minutes or so and we leave the interns to repair her tear. We head back to the resuscitation room.
In the end, we didn't have any more resuscitations but Anne-Marie catches yet another baby due to absent midwives. How strange, that in a second stage room, with five beds, each containing a labouring mother, there is no midwife. How can that be? Are they so short-staffed? Are they ignoring the calls of help from mothers? Are they so over-worked, underpaid, and apathetic that their work no longer holds any reward or joy? I could see it happening but it still just seems so bizarre that women are left to labour and birth without the benefit of caregivers.
As for the wee babe we resuscitated, well, his mom was sent off for a C-section for delivery of the second twin. Apparently the second was presenting his face (deflexed head) and not coming down so she went for cesar (as they're called here). I doubt that he'll get antibiotics but I hope that someone assessed him after we left to make sure he was still holding his own.
Two days to go.
Heather
Saturday, July 7, 2007
Apparently the title bar isn't working on the blogspot site at present so this will have to be a title-free posting. I've spent the day walking into downtown Kampala, enjoying pots of African tea while writing in my journal. I then met up with a new Ugandan friend, Favor, who is the daughter of Prossy, one of the midwives we worked with in Masaka. I had a fun afternoon talking with Favor and a couple of her friends about Ugandan economics, politics, gender dynamics - it was enlightening and great to just sit down and chat about something other than birth with some local folks.
I loved reading Anne-Marie's impressions of our week at Mulago. It's so great to compare our different perspectives, writing styles, highs and lows. I'd also encourage you to check out Brynne's family blog if you haven't yet (there's a link from this page) - Brynne's eloquent words capture so well her (our) experiences in Masaka.
Our final birth on Friday afternoon was so rewarding. Stella was a primigravida whom Anne-Marie had assessed in the late morning when she was 7 cm dilated. Around 3:30, one of the Ugandan midwives checked her and told us she was fully dilated. Anne-Marie was just finishing up with another birth and so we figured we'd have one more quick birth (remember, average Ugandan primigravida pushes for 20-30 minutes) before we headed out for the weekend. Over the next half hour, A-M attended Stella while I checked in with a few other women, monitoring fetal heart tones and checking dilation, waiting for the call from A-M that she was ready for backup. But that wee babe just wasn't coming down - after half an hour, A-M rechecked Stella's cervix to find that she wasn't fully dilated; there was an anterior lip, not swollen but definitely present. We encouraged Stella to lie on her side, try to resist the strong pushing urge, and allow time for the last of the cervix to melt away. As we stood at the bedside, we talked about what homeopathic remedies we might try if we were at home to help disappear this cervix. We both thought gelsemium, perhaps alternated with caulophyllum. But, this is Uganda, not Canada, and there weren't any homeopathics at hand so we resorted to the age-old, tried and true method of physical and emotional support to help Stella through this painful transition to fully dilated.
Another half an hour, the pushing urge was still irresistible, another vaginal exam found the cervical lip still stubbornly present. So we thought we'd try to slip that lip out of the way manually so that the babe could come down. Slipping a cervical lip involves using your fingers to push the lip up past the babe's head as the mom pushes with a contraction. Anne-Marie slipped the lip, the head came down, some but that feisty lip came back once the contraction was over. After a few more contractions, I tried slipping the lip. This time, the head really came down and the lip stayed up. But Stella was tired and overwhelmed, her contractions were spacing out, the head still wasn't visible at the perineum so we thought we'd better consult our Ugandan colleagues. It was decided that we'd hang normal saline with some oxytocin to encourage her contractions, get her some tea, and give her some more time. By this point, she'd been pushing for almost 2 hours. The babe's heart had been a solid 130 beats per minute (normal range 110-160 bpm) throughout second stage so we knew the wee one wasn't feeling the strain her mother was. Well, it wasn't long after the oxytocin was hung that we started to see this babe's black hair peeking out at us. We had two of our Ugandan colleagues standing by as Anne-Marie received this 3.5 kg baby over an intact perineum. Stella was thrilled. We were thrilled. How lovely to stay with this mom, see her through a tough second stage, to see her cuddle in with her beautiful baby girl after a long "birth" day.
This birth inspired a really interesting conversation with a couple of our Ugandan colleagues. Grace and Sarah observed the birth and the discussion of episiotomy came up yet again. Grace told us that in nursing/midwifery school, students are taught that indications for episiotomy are primigravida, premature baby, big baby, multiple pregnancy (e.g. twins), and breech. We discussed some of the research that indicates that routine episiotomy is unnecessary and harmful and that the main indication for episiotomy where we work is fetal distress. To which Grace replied, "Well, it was people from the West who came to Africa and taught us to do episiotomy in the first place. How come no one has bothered to tell us that it's no longer considered the appropriate thing to do?" Good point.
My time is short - I've got lots of thoughts on the subject of medical/cultural imperialism and changing practice but they will have to wait. Wishing you all a pleasant and joy-filled day, wherever you are in the world.
Heather
I loved reading Anne-Marie's impressions of our week at Mulago. It's so great to compare our different perspectives, writing styles, highs and lows. I'd also encourage you to check out Brynne's family blog if you haven't yet (there's a link from this page) - Brynne's eloquent words capture so well her (our) experiences in Masaka.
Our final birth on Friday afternoon was so rewarding. Stella was a primigravida whom Anne-Marie had assessed in the late morning when she was 7 cm dilated. Around 3:30, one of the Ugandan midwives checked her and told us she was fully dilated. Anne-Marie was just finishing up with another birth and so we figured we'd have one more quick birth (remember, average Ugandan primigravida pushes for 20-30 minutes) before we headed out for the weekend. Over the next half hour, A-M attended Stella while I checked in with a few other women, monitoring fetal heart tones and checking dilation, waiting for the call from A-M that she was ready for backup. But that wee babe just wasn't coming down - after half an hour, A-M rechecked Stella's cervix to find that she wasn't fully dilated; there was an anterior lip, not swollen but definitely present. We encouraged Stella to lie on her side, try to resist the strong pushing urge, and allow time for the last of the cervix to melt away. As we stood at the bedside, we talked about what homeopathic remedies we might try if we were at home to help disappear this cervix. We both thought gelsemium, perhaps alternated with caulophyllum. But, this is Uganda, not Canada, and there weren't any homeopathics at hand so we resorted to the age-old, tried and true method of physical and emotional support to help Stella through this painful transition to fully dilated.
Another half an hour, the pushing urge was still irresistible, another vaginal exam found the cervical lip still stubbornly present. So we thought we'd try to slip that lip out of the way manually so that the babe could come down. Slipping a cervical lip involves using your fingers to push the lip up past the babe's head as the mom pushes with a contraction. Anne-Marie slipped the lip, the head came down, some but that feisty lip came back once the contraction was over. After a few more contractions, I tried slipping the lip. This time, the head really came down and the lip stayed up. But Stella was tired and overwhelmed, her contractions were spacing out, the head still wasn't visible at the perineum so we thought we'd better consult our Ugandan colleagues. It was decided that we'd hang normal saline with some oxytocin to encourage her contractions, get her some tea, and give her some more time. By this point, she'd been pushing for almost 2 hours. The babe's heart had been a solid 130 beats per minute (normal range 110-160 bpm) throughout second stage so we knew the wee one wasn't feeling the strain her mother was. Well, it wasn't long after the oxytocin was hung that we started to see this babe's black hair peeking out at us. We had two of our Ugandan colleagues standing by as Anne-Marie received this 3.5 kg baby over an intact perineum. Stella was thrilled. We were thrilled. How lovely to stay with this mom, see her through a tough second stage, to see her cuddle in with her beautiful baby girl after a long "birth" day.
This birth inspired a really interesting conversation with a couple of our Ugandan colleagues. Grace and Sarah observed the birth and the discussion of episiotomy came up yet again. Grace told us that in nursing/midwifery school, students are taught that indications for episiotomy are primigravida, premature baby, big baby, multiple pregnancy (e.g. twins), and breech. We discussed some of the research that indicates that routine episiotomy is unnecessary and harmful and that the main indication for episiotomy where we work is fetal distress. To which Grace replied, "Well, it was people from the West who came to Africa and taught us to do episiotomy in the first place. How come no one has bothered to tell us that it's no longer considered the appropriate thing to do?" Good point.
My time is short - I've got lots of thoughts on the subject of medical/cultural imperialism and changing practice but they will have to wait. Wishing you all a pleasant and joy-filled day, wherever you are in the world.
Heather
Friday, July 6, 2007
All in a week's work...
hello to all you sweet blog-treaders...
i've not been posting personally to the blog so far, but it's been lovely to hear about some of your thoughts and responses to heather's posts. it adds a new dimension to our processing to share things with cyber-folks!
i've been meaning to get posting here and since it's the end of a special week at mulago hospital, ward 14, it's as good a time as any!
monday - i was stabbed with a pen and spanked a few times by a crusty local midwife; i would have spanked her back if i wasn't struck still by my disbelief. heather got a spank or two as well, so we suffered together. the day was so frustrating, as we got into true baby catching sportsmanship. we were playig defence, catching babies with elbows out, fending off midwives coming in to cut episiotomies in women's vaginas who certainly didn't need the cut, or pulling women's hair to make them push harder! i appreciate that we work within different birth cultures, and i appreciate that a colonial history is what fueled the episiotomy train in the first place, but i couldn't help but leave feeling sickened. i felt like i wouldn't be able to face this everyday; women abusing other women. violence in birth just ain't going to make the world a better place.
tuesday - a rainy afternoon. i listened to babies fast little heart beats through big bellies in a quiet labour ward. the calmness was a gift.
wednesday - i chat with a local restaurant owner who shivers when i tell him that i am a student midwife. i ask why. he tells me that midwives are ruthless and violent. this reply rings familiar with the local belief that the midwife is a woman's worst enemy. i go into work in the afternoon and have a chat with the head midwife on the ward and her mother who is also a midwife. she's so rad and she is totally supportive of learning more gentle approaches to birth. we talked about tonnes of stuff...midwives' dissatisfaction with their work, poor pay, stress, power trips over women, modelling behaviour, ideas about how to motivate women, lack of educational opportunities, religion and birth... she really wants heather and i to do some teaching with the midwives and we're both super stoked for that opportunity!
thursday - incredible. it's a slow day on the ward, permitting some time for teaching and disussion. we started by talking about the importance of administering oxytocin with normal saline, rather than dextrose, and we pulled out the alarm manual to justify our case. we talked about using oxytocin rather than ergot for the management of third stage. we then demonstrated shoulder dystocia and breech birth management, as if we were a bunch of pros. then i went off on a big ol' rant about midwives being privileged to do the blessed work that we do. most of these women are christian, so i talked jesus talk and ranted about the incredible responsibility we have as god's servants to invite new human beings onto the planet in peace and without violence. i talked about sisterhood between midwives and the women we support, and the need to make one of life's most challenging experiences as pleasant for women as possible. the few nods of agreement that i saw were enough to make me swell with bubbles of joy. even if they are a little kinder to one or two women this week, that's important.
and by friday... - the midwives are stepping back and watching. they are interested in the differences between how we catch babies and the midwife who stabbed us on monday now has given me her name and calls us sisters. she likes the little knit dolls that we brought from canada and she keeps trying to breastfeed them; kinda creepy, but it's better thank spanking! we attended 6 lovely births today and left smiling!
peace...a-m
i've not been posting personally to the blog so far, but it's been lovely to hear about some of your thoughts and responses to heather's posts. it adds a new dimension to our processing to share things with cyber-folks!
i've been meaning to get posting here and since it's the end of a special week at mulago hospital, ward 14, it's as good a time as any!
monday - i was stabbed with a pen and spanked a few times by a crusty local midwife; i would have spanked her back if i wasn't struck still by my disbelief. heather got a spank or two as well, so we suffered together. the day was so frustrating, as we got into true baby catching sportsmanship. we were playig defence, catching babies with elbows out, fending off midwives coming in to cut episiotomies in women's vaginas who certainly didn't need the cut, or pulling women's hair to make them push harder! i appreciate that we work within different birth cultures, and i appreciate that a colonial history is what fueled the episiotomy train in the first place, but i couldn't help but leave feeling sickened. i felt like i wouldn't be able to face this everyday; women abusing other women. violence in birth just ain't going to make the world a better place.
tuesday - a rainy afternoon. i listened to babies fast little heart beats through big bellies in a quiet labour ward. the calmness was a gift.
wednesday - i chat with a local restaurant owner who shivers when i tell him that i am a student midwife. i ask why. he tells me that midwives are ruthless and violent. this reply rings familiar with the local belief that the midwife is a woman's worst enemy. i go into work in the afternoon and have a chat with the head midwife on the ward and her mother who is also a midwife. she's so rad and she is totally supportive of learning more gentle approaches to birth. we talked about tonnes of stuff...midwives' dissatisfaction with their work, poor pay, stress, power trips over women, modelling behaviour, ideas about how to motivate women, lack of educational opportunities, religion and birth... she really wants heather and i to do some teaching with the midwives and we're both super stoked for that opportunity!
thursday - incredible. it's a slow day on the ward, permitting some time for teaching and disussion. we started by talking about the importance of administering oxytocin with normal saline, rather than dextrose, and we pulled out the alarm manual to justify our case. we talked about using oxytocin rather than ergot for the management of third stage. we then demonstrated shoulder dystocia and breech birth management, as if we were a bunch of pros. then i went off on a big ol' rant about midwives being privileged to do the blessed work that we do. most of these women are christian, so i talked jesus talk and ranted about the incredible responsibility we have as god's servants to invite new human beings onto the planet in peace and without violence. i talked about sisterhood between midwives and the women we support, and the need to make one of life's most challenging experiences as pleasant for women as possible. the few nods of agreement that i saw were enough to make me swell with bubbles of joy. even if they are a little kinder to one or two women this week, that's important.
and by friday... - the midwives are stepping back and watching. they are interested in the differences between how we catch babies and the midwife who stabbed us on monday now has given me her name and calls us sisters. she likes the little knit dolls that we brought from canada and she keeps trying to breastfeed them; kinda creepy, but it's better thank spanking! we attended 6 lovely births today and left smiling!
peace...a-m
Thursday, July 5, 2007
Creating space
Well, after four days working on Ward 14 at Mulago Hospital, I really feel like we've created a niche for ourselves. I think most of the midwives now trust that we know what we're doing, that we can manage births independently, and that we have good outcomes, in spite of the fact that we manage births very differently than they do. There even seems to be an increasing interest in the high number of intact perineums that we have, especially in the "P.G.s" (primigravidas) we've been attending. The head midwife on the ward, Sarah, is so eager to talk about skills and techniques that we've brought with us from home - she was thrilled today when we gave her a copy of the Canadian ALARM textbook that we'd brought from home. She is a woman with an warm heart who wants to provide good care to the mothers that they serve at Mulago. This public hospital maternity ward (and the midwives who work there) have a poor reputation among the general public - if women can afford to go elsewhere they do. I think Sarah is aware of this and wants to change it and is recognizing that how women are treated impacts their own experience and public perception of maternity care at the hospital. Today we had a really good teaching session with the day-shift midwives - Anne-Marie is going to post about this soon so I won't go into it in any detail except to say that it was gratifying and encouraging to talk about birth with the midwives we work with on a daily basis.
I attended a lovely birth at the end of the day today. A-M had already gone home because she'd been feeling a little "off" but I decided to stay out the day. A P.G. who had been on the ward since mid-morning was sounding quite active so I checked her to find her 8-9 cm dilated. Shortly afterwards, one of the Ugandan midwives, Grace, checked her again as she was feeling the urge to push. She was fully dilated so Grace ruptured her membranes. I asked if I could catch the baby, and Grace asked me if I could suture an episiotomy. I assured her that there would be no episiotomy if I was catching and that there was a good chance of no tear. I don't think Grace really believed me (she has been working evening shift and so hasn't seen us catch yet) but I told her that if there was a tear I would suture. I guess in Canadian terms, her pushing stage was pretty short (15 minutes) but Ugandan midwives are used to telling women to push like stink once they have reached full dilatation, whether they are having a contraction or not. I think Grace got a little impatient as I was telling this woman to rest and breathe between contractions so the head didn't pop out within five minutes of pushing. Grace asked me to call her once the head was crowning so she could see how I "delivered" the head. The head crowned, I told the mama to stop pushing, she breathed her baby out nice and slow, and then the shoulders and body came easily and babe was up to mom's tummy. No tears, no episiotomy. I'm quite sure that had Grace attended this delivery, this mom would have had an episiotomy. As we inspected the perineum together, I asked Grace what she thought about the delivery. While know she was happy there was no tear, she was sure to tell me that it was only because it was a small baby (2.7 kg). Ah well, whether it was a small baby, a stretchy perineum, a slow and controlled delivery of the head, I'm just pleased that this mama can settle down to loving her baby with an intact vagina.
It seems amazing that we have only 6 days of work left here in Uganda. At first, as we adjusted to a new birthing culture, lack of supplies, a different language, the days passed so slowly, each day full of rich new experiences. But as inevitably happens when one becomes more comfortable and settled in a new place, the time speeds up. Suddenly we're facing the end of our placement. Some days I feel ready for a break, ready to travel and experience Uganda from a perspective other than that of a maternity care worker. But other days, like today, I feel like I'm just getting into the groove, just finding my place here - I can't be nearly finished. It's just been such a privilege to experience birth in another country, to care for Ugandan women. We have been so lucky to been given independence to catch babies the "Canadian way" in the midst of this big public hospital. The low-risk ward where we're working has an average of 30 births per 24 hours. Down on the high-risk ward, they're welcoming 60-70 new babes into the world every day. It is so completely different from the midwifery care environment in Canada. But working here has given me so much more confidence in my skills. Catching baby after baby, day after day, really has reassured me that most of the time, birth works, often in spite of poor health, lack of antenatal care, rudimentary supplies.
Brynne will be leaving Masaka next Wednesday as she and her family travel home to Bowen Island. I had an email from her today - it sounds like she has been entrusted with the management of most of the deliveries in Masaka since we left. She is, I am sure, attending those mothers with grace and skill, while enthusiastically teaching the many nursing students that seem to be continually present in labour and delivery at Masaka. I think she and her family are feeling really at home in Masaka - it will be difficult for them to leave after such life-changing experiences for all of them.
Until next time,
Heather
I attended a lovely birth at the end of the day today. A-M had already gone home because she'd been feeling a little "off" but I decided to stay out the day. A P.G. who had been on the ward since mid-morning was sounding quite active so I checked her to find her 8-9 cm dilated. Shortly afterwards, one of the Ugandan midwives, Grace, checked her again as she was feeling the urge to push. She was fully dilated so Grace ruptured her membranes. I asked if I could catch the baby, and Grace asked me if I could suture an episiotomy. I assured her that there would be no episiotomy if I was catching and that there was a good chance of no tear. I don't think Grace really believed me (she has been working evening shift and so hasn't seen us catch yet) but I told her that if there was a tear I would suture. I guess in Canadian terms, her pushing stage was pretty short (15 minutes) but Ugandan midwives are used to telling women to push like stink once they have reached full dilatation, whether they are having a contraction or not. I think Grace got a little impatient as I was telling this woman to rest and breathe between contractions so the head didn't pop out within five minutes of pushing. Grace asked me to call her once the head was crowning so she could see how I "delivered" the head. The head crowned, I told the mama to stop pushing, she breathed her baby out nice and slow, and then the shoulders and body came easily and babe was up to mom's tummy. No tears, no episiotomy. I'm quite sure that had Grace attended this delivery, this mom would have had an episiotomy. As we inspected the perineum together, I asked Grace what she thought about the delivery. While know she was happy there was no tear, she was sure to tell me that it was only because it was a small baby (2.7 kg). Ah well, whether it was a small baby, a stretchy perineum, a slow and controlled delivery of the head, I'm just pleased that this mama can settle down to loving her baby with an intact vagina.
It seems amazing that we have only 6 days of work left here in Uganda. At first, as we adjusted to a new birthing culture, lack of supplies, a different language, the days passed so slowly, each day full of rich new experiences. But as inevitably happens when one becomes more comfortable and settled in a new place, the time speeds up. Suddenly we're facing the end of our placement. Some days I feel ready for a break, ready to travel and experience Uganda from a perspective other than that of a maternity care worker. But other days, like today, I feel like I'm just getting into the groove, just finding my place here - I can't be nearly finished. It's just been such a privilege to experience birth in another country, to care for Ugandan women. We have been so lucky to been given independence to catch babies the "Canadian way" in the midst of this big public hospital. The low-risk ward where we're working has an average of 30 births per 24 hours. Down on the high-risk ward, they're welcoming 60-70 new babes into the world every day. It is so completely different from the midwifery care environment in Canada. But working here has given me so much more confidence in my skills. Catching baby after baby, day after day, really has reassured me that most of the time, birth works, often in spite of poor health, lack of antenatal care, rudimentary supplies.
Brynne will be leaving Masaka next Wednesday as she and her family travel home to Bowen Island. I had an email from her today - it sounds like she has been entrusted with the management of most of the deliveries in Masaka since we left. She is, I am sure, attending those mothers with grace and skill, while enthusiastically teaching the many nursing students that seem to be continually present in labour and delivery at Masaka. I think she and her family are feeling really at home in Masaka - it will be difficult for them to leave after such life-changing experiences for all of them.
Until next time,
Heather
Monday, July 2, 2007
Settling in to Kampala
Hello to the many folks keeping in touch with our work through this blog. It's been so lovely to read your notes and warm wishes - your interest in our work here inspires me to keep posting regularly.
Anne-Marie and I have found cheap, convenient digs in Kampala, quite close to Mulago Hospital where we're working this week and next. We're staying at a university hostel, called Akamwesi Hostel. Generally university students fill up this hostel but they are on a break from classes at present so there is a room available for us for the next two weeks. There are even cooking facilities, which is wonderful, as eating out every day starts to get a little wearing.
Today was our first day working on our own without Cathy providing instruction and support. While I couldn't imagine managing births without Cathy's support when we first arrived, I think both Anne-Marie and I felt quite confident as we worked in labur and delivery on the low-risk ward today. We've become pretty confident with managing births Ugandan style and no longer have any qualms about tying cords with the cuffs from gloves or cutting cords with razor blades. It's also become really normal to attend women who are lying on a piece of plastic that they've brought themselves, layed out on an old vinyl-covered mattress. We clean up with pieces of cotton batting torn from a roll brought by the women; we also use this cotton to clean away clots of blood so that we can examine their perineums after the birth. The gloves we use, the razor blade, syringes and needles for active management, the basin - all of these items are provided by the birthing women. It's not ideal but it works. And you know, compared to a birth in a hospital in Canada, there's very little waste - the plastic sheet, some wet cotton batting, the used gloves. That's about it. All the amniotic fluid, blood, etc. from the birth gets wrapped up in the plastic. We use the cotton batting to wipe off the woman's body. She stands up, uses cotton as a pad between her legs, puts on her clothes, lays out another cloth on the bed, and lies down again with her babe. It always amazes me how quickly women go from the intense effort of birthing their babies to fully dressed, phoning their relatives on their cell phones (yup, some of them have cell phones - they're pretty ubiquitous in Kampala), while lying down nursing their babes. The transition just seems so quick.
One of the challenges that we seem to be frequently faced with is misuse of medications. All women birthing at Ugandan public hospitals are supposed to be offered active management of the third stage of labour. This means that within a minute of the birth of the baby, the mother is given an injection of oxytocin to help the uterus contract, the placenta separate, and to reduce postpartum bleeding. In a place where many pregnant women are anemic, more than 10% are HIV positive, and IV fluids and blood for transfusion is scarce, active management makes good sense and I've certainly embraced this policy. The problem that we've encountered, however, is that often labour wards don't have oxytocin. And so they're using ergometrine for active management instead. Ergometrine is a drug that is used selectively in Canada (if you can even access it) - it's second line treatment for postpartum hemorrhage and is only used if the placenta is out and is complete, oxytocin has failed to contract the uterus efficiently, and the woman is continuing to bleed heavily. It's contraindicated if the woman has high blood pressure. It also requires refrigeration to be effective. Here we see ergometrine used over and over for active management. It's given like oxytocin would be - intramuscularly within one minute of the birth. We've been providing oxytocin on labour wards in both Masaka and here in Kampala because it often seems that it's just not available. But more than that, it seems that many midwives don't understand that ergometrine isn't an appropriate drug to be using in this manner. While they know that oxytocin is better, the potential complications of using ergometrine aren't recognized. It feels like we're frequently discussing appropriate active management of third stage and encouraging midwives and students to use oxytocin. But what do you do when there's no oxy available? Is ergometrine, despite its problems, better than nothing? I really don't know. All we can do is keep bringing our own oxytocin so that the women we attend at least get appropriate management but there are obviously systems problems, supply problems, and miseducation. That seems like barriers that are too large for us to tackle in the short time we're here.
Today A-M and I each caught two babies. For the most part, all the births were uncomplicated, though the biggest challenge was trying to firmly hold our ground and manage the births in our style. We support women differently than the Ugandan midwives, especially during second stage when we encourage a slow delivery of the baby's head to allow the perineum to stretch and prevent tears. Most of the midwives we've worked with here get the women to push like crazy and episiotomies are much more common, especially with first time mothers. Today it felt as though we were frequently fending off well-meaning but inappropriate directions from our colleagues. We know how to catch babies. We've done a lot of it now. We have really good success with promoting intact perineums. And yet we have to continually defend the way we manage second stage. It's draining and sometimes hard to keep our sense of humour and a positive perspective. But we did have a lovely success today - Sarah, the head midwife on the ward, attended a birth with us. Anne-Marie was catching and encouraged a really slow delivery of the baby. Afterwards Sarah said that she really liked the way A-M managed second stage and admitted that midwives in Uganda tend to get scared if pushing takes a long time or the head stays on the perineum too long. She said that she thinks sometimes women tear who shouldn't because the head comes out too fast. I think we may have a convert!
There will be lots of babies on Ward 14 at Mulago. Overall I'm looking forward to the next two weeks. Lots of learning to be done, and perhaps some teaching as well.
Tunalabagana (see you later!)
Heather
Anne-Marie and I have found cheap, convenient digs in Kampala, quite close to Mulago Hospital where we're working this week and next. We're staying at a university hostel, called Akamwesi Hostel. Generally university students fill up this hostel but they are on a break from classes at present so there is a room available for us for the next two weeks. There are even cooking facilities, which is wonderful, as eating out every day starts to get a little wearing.
Today was our first day working on our own without Cathy providing instruction and support. While I couldn't imagine managing births without Cathy's support when we first arrived, I think both Anne-Marie and I felt quite confident as we worked in labur and delivery on the low-risk ward today. We've become pretty confident with managing births Ugandan style and no longer have any qualms about tying cords with the cuffs from gloves or cutting cords with razor blades. It's also become really normal to attend women who are lying on a piece of plastic that they've brought themselves, layed out on an old vinyl-covered mattress. We clean up with pieces of cotton batting torn from a roll brought by the women; we also use this cotton to clean away clots of blood so that we can examine their perineums after the birth. The gloves we use, the razor blade, syringes and needles for active management, the basin - all of these items are provided by the birthing women. It's not ideal but it works. And you know, compared to a birth in a hospital in Canada, there's very little waste - the plastic sheet, some wet cotton batting, the used gloves. That's about it. All the amniotic fluid, blood, etc. from the birth gets wrapped up in the plastic. We use the cotton batting to wipe off the woman's body. She stands up, uses cotton as a pad between her legs, puts on her clothes, lays out another cloth on the bed, and lies down again with her babe. It always amazes me how quickly women go from the intense effort of birthing their babies to fully dressed, phoning their relatives on their cell phones (yup, some of them have cell phones - they're pretty ubiquitous in Kampala), while lying down nursing their babes. The transition just seems so quick.
One of the challenges that we seem to be frequently faced with is misuse of medications. All women birthing at Ugandan public hospitals are supposed to be offered active management of the third stage of labour. This means that within a minute of the birth of the baby, the mother is given an injection of oxytocin to help the uterus contract, the placenta separate, and to reduce postpartum bleeding. In a place where many pregnant women are anemic, more than 10% are HIV positive, and IV fluids and blood for transfusion is scarce, active management makes good sense and I've certainly embraced this policy. The problem that we've encountered, however, is that often labour wards don't have oxytocin. And so they're using ergometrine for active management instead. Ergometrine is a drug that is used selectively in Canada (if you can even access it) - it's second line treatment for postpartum hemorrhage and is only used if the placenta is out and is complete, oxytocin has failed to contract the uterus efficiently, and the woman is continuing to bleed heavily. It's contraindicated if the woman has high blood pressure. It also requires refrigeration to be effective. Here we see ergometrine used over and over for active management. It's given like oxytocin would be - intramuscularly within one minute of the birth. We've been providing oxytocin on labour wards in both Masaka and here in Kampala because it often seems that it's just not available. But more than that, it seems that many midwives don't understand that ergometrine isn't an appropriate drug to be using in this manner. While they know that oxytocin is better, the potential complications of using ergometrine aren't recognized. It feels like we're frequently discussing appropriate active management of third stage and encouraging midwives and students to use oxytocin. But what do you do when there's no oxy available? Is ergometrine, despite its problems, better than nothing? I really don't know. All we can do is keep bringing our own oxytocin so that the women we attend at least get appropriate management but there are obviously systems problems, supply problems, and miseducation. That seems like barriers that are too large for us to tackle in the short time we're here.
Today A-M and I each caught two babies. For the most part, all the births were uncomplicated, though the biggest challenge was trying to firmly hold our ground and manage the births in our style. We support women differently than the Ugandan midwives, especially during second stage when we encourage a slow delivery of the baby's head to allow the perineum to stretch and prevent tears. Most of the midwives we've worked with here get the women to push like crazy and episiotomies are much more common, especially with first time mothers. Today it felt as though we were frequently fending off well-meaning but inappropriate directions from our colleagues. We know how to catch babies. We've done a lot of it now. We have really good success with promoting intact perineums. And yet we have to continually defend the way we manage second stage. It's draining and sometimes hard to keep our sense of humour and a positive perspective. But we did have a lovely success today - Sarah, the head midwife on the ward, attended a birth with us. Anne-Marie was catching and encouraged a really slow delivery of the baby. Afterwards Sarah said that she really liked the way A-M managed second stage and admitted that midwives in Uganda tend to get scared if pushing takes a long time or the head stays on the perineum too long. She said that she thinks sometimes women tear who shouldn't because the head comes out too fast. I think we may have a convert!
There will be lots of babies on Ward 14 at Mulago. Overall I'm looking forward to the next two weeks. Lots of learning to be done, and perhaps some teaching as well.
Tunalabagana (see you later!)
Heather
Saturday, June 30, 2007
A Birth you won't find in William's Obstetrics
Hello all - greetings from Kampala. It's a hot Saturday afternoon and I've been exploring the city with my friends Lindsey and Andrea. It was time to get out of the heat and take refuge in an internet cafe with air conditioning! I'm hoping the power doesn't go out so that I can complete this post.
Yesterday was an amazing day. Cathy, Anne-Marie, and I spent the day at New Mulago Hospital on the high risk ward. While there were plenty of interesting cases to manage and a lovely spontaneous vaginal delivery for a woman with high blood pressure, there's one birth in particular that I'm going to write about today. It was heart-stopping, incredible, scary, and exhilarating. In the afternoon we were managing various women's induction IVs and checking in on fetal hearts and trying to ensure other women were getting their meds when the intern from admissions came down to the ward telling us they had a woman with twins already pushing. We looked down the hall to see her awkwardly making her way down towards us, her plastic in hand. The intern quickly told us that the first baby was breech, and that the second one probably was too! Great, we thought, a twin birth and two breeches, all in one! Anne-Marie had put a wish out for a breech that morning and I had said that I wanted to see twins - here it was, all in one. As the saying goes...be careful what you wish for.
Thankfully there was a spare bed - we didn't have to dislodge anyone to find a place for her to birth her babies. But a birthing bed in Uganda is pretty different than a birthing bed in the typical hospital in Canada. Metal frame, no break-away, no stirrups, heck, half of them are partially broken and lurching at strange angles. We got her plastic spread and helped her on to the bed, having her lie down sort of across it at an angle so that her hips were at the edge of the bed. The maneuvers that you do to assist a breech babe require having some room to lower the babe's body after it's born but before the head is out. As soon as we got her settled, we could see the breech at the perineum. Anne-Marie and Cathy managed the catch, with the Intern David standing by and me providing support as well. It was a fairly straight-forward breech delivery - Cathy splinted and removed one leg and Anne-Marie did the other. The arms came easily as they weren't up above the head. The head was slightly difficult but was birthed after a few moments. Babe was great - she was breathing shortly after birth with just some stimulation and drying.
Cathy did a vaginal exam to find out where the second twin was. The presenting part was really quite high still so David and Cathy thought we should hang some oxytocin, a medication that stimulates uterine contractions, to keep the contractions strong and bring the second babe down into the pelvis. Before we could do this, there was a major gush of blood, spurting from the woman's vagina. A placental abruption. The blood kept pouring out. We couldn't get a fetal heart (we're using a manual fetoscope - no doppler here). We started talking about taking the woman to surgery because there was a good chance of her bleeding out before the second twin could be born. Things started to settle a wee bit, so Cathy did another exam. She feels a foot, or, no, it's a hand...and beside the hand, a placenta. A hand (which might mean a shoulder presentation)and a placenta presenting. What do you do? The pace picked up, trying to get an IV hung, blood taken for typing and cross-matching in preparation for C/S. But in the mean time, the placenta came down into the vagina and was at the introitus. What do you do with a placenta that's coming before the second twin? They don't write about that in text books! And the scariest part is, you don't know if this placenta is only for the twin that's been born or for both twins, which is a real possiblity. Often twins share a placenta, whether it's simply one or two that have fused.
Cathy was holding the placenta at the introitus of the vagina, and then it was born. And there was only one umbilical cord attached to it. The next exam, Cathy felt the 2nd baby's head, and the hand, and the umbilical cord. Which was pulsating. But there's an umbilical cord prolapse. There's a strong chance of asphyxiation for a baby when the cord comes down before its head. Take a breath. Be calm. This babe will be born. There's no time to get to surgery. We were stimulating the woman's nipples, trying to provoke more contractions, oxytocin was running, Cathy had some success pushing the hand back to allow the head to come down. David was praying, the Ugandan midwife Eunice was praying, I think we were all sending our prayers to the spirits and deities. And then suddenly, the babe was born, hand waving at us. The cord was tied and cut, she was stimulated, she made a few grunts and was rushed off to the resuscitation room with A-M. And she had a little positive pressure ventilation with a bag and mask and was fine. We gave the mother more oxytocin, both intramuscularly and IV, and the second placenta came quickly. Her bleeding after the second babe was fairly minimal. Her uterus contracted beautifully. She had two healthy baby girls after a breech birth, placental abruption, hemorrhage, hand presentation, and cord prolapse. Turns out she also had high blood pressure. Oh my. How blessed she is. How strong she is. After Cathy sutured her second degree tear, she was ready to get up and get some food. She couldn't understand why we wanted her to stay lying down with an IV running for a a while.
Despite a few challenges, including the unwillingness of various midwives to take her blood to the lab for type and cross-match ("I'm not working on that ward, it's not my job, you'll have to wait for the correct midwife to come back from lunch."), I think that we worked wonderfully well with the intern David and the midwife Eunice. As further complications appeared, we dealt with them. It was an amazing birth. It was a scary birth. It was birth in Uganda.
With blessings for you all,
Heather
Yesterday was an amazing day. Cathy, Anne-Marie, and I spent the day at New Mulago Hospital on the high risk ward. While there were plenty of interesting cases to manage and a lovely spontaneous vaginal delivery for a woman with high blood pressure, there's one birth in particular that I'm going to write about today. It was heart-stopping, incredible, scary, and exhilarating. In the afternoon we were managing various women's induction IVs and checking in on fetal hearts and trying to ensure other women were getting their meds when the intern from admissions came down to the ward telling us they had a woman with twins already pushing. We looked down the hall to see her awkwardly making her way down towards us, her plastic in hand. The intern quickly told us that the first baby was breech, and that the second one probably was too! Great, we thought, a twin birth and two breeches, all in one! Anne-Marie had put a wish out for a breech that morning and I had said that I wanted to see twins - here it was, all in one. As the saying goes...be careful what you wish for.
Thankfully there was a spare bed - we didn't have to dislodge anyone to find a place for her to birth her babies. But a birthing bed in Uganda is pretty different than a birthing bed in the typical hospital in Canada. Metal frame, no break-away, no stirrups, heck, half of them are partially broken and lurching at strange angles. We got her plastic spread and helped her on to the bed, having her lie down sort of across it at an angle so that her hips were at the edge of the bed. The maneuvers that you do to assist a breech babe require having some room to lower the babe's body after it's born but before the head is out. As soon as we got her settled, we could see the breech at the perineum. Anne-Marie and Cathy managed the catch, with the Intern David standing by and me providing support as well. It was a fairly straight-forward breech delivery - Cathy splinted and removed one leg and Anne-Marie did the other. The arms came easily as they weren't up above the head. The head was slightly difficult but was birthed after a few moments. Babe was great - she was breathing shortly after birth with just some stimulation and drying.
Cathy did a vaginal exam to find out where the second twin was. The presenting part was really quite high still so David and Cathy thought we should hang some oxytocin, a medication that stimulates uterine contractions, to keep the contractions strong and bring the second babe down into the pelvis. Before we could do this, there was a major gush of blood, spurting from the woman's vagina. A placental abruption. The blood kept pouring out. We couldn't get a fetal heart (we're using a manual fetoscope - no doppler here). We started talking about taking the woman to surgery because there was a good chance of her bleeding out before the second twin could be born. Things started to settle a wee bit, so Cathy did another exam. She feels a foot, or, no, it's a hand...and beside the hand, a placenta. A hand (which might mean a shoulder presentation)and a placenta presenting. What do you do? The pace picked up, trying to get an IV hung, blood taken for typing and cross-matching in preparation for C/S. But in the mean time, the placenta came down into the vagina and was at the introitus. What do you do with a placenta that's coming before the second twin? They don't write about that in text books! And the scariest part is, you don't know if this placenta is only for the twin that's been born or for both twins, which is a real possiblity. Often twins share a placenta, whether it's simply one or two that have fused.
Cathy was holding the placenta at the introitus of the vagina, and then it was born. And there was only one umbilical cord attached to it. The next exam, Cathy felt the 2nd baby's head, and the hand, and the umbilical cord. Which was pulsating. But there's an umbilical cord prolapse. There's a strong chance of asphyxiation for a baby when the cord comes down before its head. Take a breath. Be calm. This babe will be born. There's no time to get to surgery. We were stimulating the woman's nipples, trying to provoke more contractions, oxytocin was running, Cathy had some success pushing the hand back to allow the head to come down. David was praying, the Ugandan midwife Eunice was praying, I think we were all sending our prayers to the spirits and deities. And then suddenly, the babe was born, hand waving at us. The cord was tied and cut, she was stimulated, she made a few grunts and was rushed off to the resuscitation room with A-M. And she had a little positive pressure ventilation with a bag and mask and was fine. We gave the mother more oxytocin, both intramuscularly and IV, and the second placenta came quickly. Her bleeding after the second babe was fairly minimal. Her uterus contracted beautifully. She had two healthy baby girls after a breech birth, placental abruption, hemorrhage, hand presentation, and cord prolapse. Turns out she also had high blood pressure. Oh my. How blessed she is. How strong she is. After Cathy sutured her second degree tear, she was ready to get up and get some food. She couldn't understand why we wanted her to stay lying down with an IV running for a a while.
Despite a few challenges, including the unwillingness of various midwives to take her blood to the lab for type and cross-match ("I'm not working on that ward, it's not my job, you'll have to wait for the correct midwife to come back from lunch."), I think that we worked wonderfully well with the intern David and the midwife Eunice. As further complications appeared, we dealt with them. It was an amazing birth. It was a scary birth. It was birth in Uganda.
With blessings for you all,
Heather
Thursday, June 28, 2007
Return to Kampala
A very quick post to say that Cathy, Mickey and I returned to Kampala today. We spent the afternoon working in the high risk ward at Mulago Hospital and will return there tomorrow for the full day. It wasn't a particularly busy shift this afternoon but every patient has complications or high-risk status so I expect tomorrow will hold many learning opportunities.
Our final day in Masaka was really good. We attended a couple of normal births, I assisted Mickey at another post-miscarriage procedure, there were IV successes, and it felt like our work there as a group ended on a good note. Brynne is staying on for two more weeks.
I'm just about to meet some folks for Indian food at the Masala Chaat restaurant in downtown Kampala so must run. I'm going to Jinja this weekend to river raft on the headwaters of the Nile - will try to post before I go but if not, shall catch you all up on our experiences and adventures early next week.
In peace,
Heather
Our final day in Masaka was really good. We attended a couple of normal births, I assisted Mickey at another post-miscarriage procedure, there were IV successes, and it felt like our work there as a group ended on a good note. Brynne is staying on for two more weeks.
I'm just about to meet some folks for Indian food at the Masala Chaat restaurant in downtown Kampala so must run. I'm going to Jinja this weekend to river raft on the headwaters of the Nile - will try to post before I go but if not, shall catch you all up on our experiences and adventures early next week.
In peace,
Heather
Tuesday, June 26, 2007
Long day, short day
It's Tuesday afternoon, Brynne and I finished work a little early today because we stayed really late last night. Anne-Marie finished a wee bit early yesterday to do some work on the donation of some mattresses for the postpartum and labour wards that we are trying to get organized before we leave for Kampala. So she's staying at the hospital a little later this afternoon. What a whirlwind of an evening it was yesterday! The day had been relatively quiet - Anne-Marie had caught a baby with Brynne in attendance as her second. I had attended two C-sections with Cathy to receive the baby - hopes of getting some experience with resuscitation but both babes were born healthy and crying (yay!) so I just did the usual drying, weighing, showing the babe to the mama. I was actually surprised because both these women received spinal anaesthetic rather than a general - most women have a general for a C-section here. I'm not sure why the change but it was so nice for the women to see their babes right away and not to feel so dopey after the surgery. One of the babes was born with extra digits on both hands - just small underdeveloped fingers attached to the side of the baby finger by a thin piece of skin. This seems to be relatively common here - this is the third babe we've seen with extra digits since we started our work at Masaka. Treatment is as simple as using some suture material to tie off the extra digits - they will then fall off within a week or so as the blood supply is cut off. The babes definitely feel a little pain as you tie off the digit but then they settle down quite quickly and seem to do just fine.
Around 4pm yesterday, things started to get quite busy. We had three primigravidas (first time mothers) in labour, all well along. There was also another woman who had been labouring all day but was waiting for C/S. By this time A-M had left, so Cathy, Brynne and I were managing things on the ward. I believe there were still some Ugandan students around for the first part of the chaos. Brynne and I each caught a babe within about 20 minutes of each other. The woman I was attending ended up with a second degree perineal tear. The babe was having decelerations during the pushing stage with slow recovery so we encouraged her to push quite hard...this may have contributed to the tear, or perhaps she would have torn even with a nice slow delivery. It's always hard to know. The babe did need some resuscitation, which Cathy did. I remained with the mother to see her through delivery of the placenta. Babe was fine. We did suture her tear, most of which I did, finished off by Cathy as my frustration and fatige mounted. I still feel pretty sketchy when it comes to suturing. The birth Brynne attended went well, intact perineum, happy mother, no complications. The third woman had been transferred into Masaka from a rural centre. It was extremely difficult to get a clear picture from her about what her situation was - at one point we understood that she'd been pushing for the whole day, later it seemed that it had only been one hour. Though the baby's head was at the perineum, it would not come around the pubic bone. The OB assessed her, felt that there was a large amount of caput with no further descent and decided to do a C/S. Apparently the babe was born alive but resuscitation was not successful.
Somewhere in the midst of all this activity, all the Ugandan students went home, the Ugandan staff were busy elsewhere, and we three Canadians were alone in labour and delivery. How challenging as women just kept walking into the ward, putting their sheets of plastic on the bed, and lying down. Talk about a communication gap - we would ask for their antenatal cards in simple English, rudimentary Lugandan, and our own special "birth sign language" and then try to piece together where they'd come from, what was happening for them, etc. We ended up attending a third primigravida who basically came in pushing. We were going to hand off to our Ugandan colleagues but then the head was at the perineum and it seemed to make sense to carry on and attend her birth. She had a normal birth, though I called her by the wrong name throughout second and third stage - ack! Cathy sutured two moderate labial tears, tears that we would probably not suture at home, but here it's felt that because women often don't have soap to wash with, infection is more likely if you don't suture. As this was happening, another woman walked in with blood running down her leg. Again, there was incredible difficulty figuring out what was happening for her. Eventually it became clear that she was 34 weeks pregnant with a complete placenta previa (placenta implanted over the cervix). She had an antepartum hemorrhage. There were no doctors on site. There was no one in the lab to type and cross-match her blood. The midwife who eventually arrived was trying to call in a doctor and the lab so that we could get her to surgery. They took her off to surgery just before we left. By the time we were gone there was still no doctor. We found out this morning that they did a C/S (babe already dead), transfused her with two units of blood during and just after surgery with orders to transfuse her with two more units post-op. She died on the postpartum ward before they could give the second two units. This was her ninth pregnancy. According to her file she had three living children at home. What a loss. How challenging for the staff here, not to have doctors, anaethetists, lab personnel on site. It is a big blow to have a maternal death, especially at the referral hospital. Such sad news to arrive to today.
It was a much slower day today - two vaginal births, which Anne-Marie and Brynne managed. I attended a dilation and curettage for an incomplete miscarriage with Mickey. I also successfully sited two IVs today on my first go, which was encouraging. It was nice to leave a little early, when all was calm, and have a little time to post to the blog.
Waylaba (goodbye in Lugandan)
Heather
Around 4pm yesterday, things started to get quite busy. We had three primigravidas (first time mothers) in labour, all well along. There was also another woman who had been labouring all day but was waiting for C/S. By this time A-M had left, so Cathy, Brynne and I were managing things on the ward. I believe there were still some Ugandan students around for the first part of the chaos. Brynne and I each caught a babe within about 20 minutes of each other. The woman I was attending ended up with a second degree perineal tear. The babe was having decelerations during the pushing stage with slow recovery so we encouraged her to push quite hard...this may have contributed to the tear, or perhaps she would have torn even with a nice slow delivery. It's always hard to know. The babe did need some resuscitation, which Cathy did. I remained with the mother to see her through delivery of the placenta. Babe was fine. We did suture her tear, most of which I did, finished off by Cathy as my frustration and fatige mounted. I still feel pretty sketchy when it comes to suturing. The birth Brynne attended went well, intact perineum, happy mother, no complications. The third woman had been transferred into Masaka from a rural centre. It was extremely difficult to get a clear picture from her about what her situation was - at one point we understood that she'd been pushing for the whole day, later it seemed that it had only been one hour. Though the baby's head was at the perineum, it would not come around the pubic bone. The OB assessed her, felt that there was a large amount of caput with no further descent and decided to do a C/S. Apparently the babe was born alive but resuscitation was not successful.
Somewhere in the midst of all this activity, all the Ugandan students went home, the Ugandan staff were busy elsewhere, and we three Canadians were alone in labour and delivery. How challenging as women just kept walking into the ward, putting their sheets of plastic on the bed, and lying down. Talk about a communication gap - we would ask for their antenatal cards in simple English, rudimentary Lugandan, and our own special "birth sign language" and then try to piece together where they'd come from, what was happening for them, etc. We ended up attending a third primigravida who basically came in pushing. We were going to hand off to our Ugandan colleagues but then the head was at the perineum and it seemed to make sense to carry on and attend her birth. She had a normal birth, though I called her by the wrong name throughout second and third stage - ack! Cathy sutured two moderate labial tears, tears that we would probably not suture at home, but here it's felt that because women often don't have soap to wash with, infection is more likely if you don't suture. As this was happening, another woman walked in with blood running down her leg. Again, there was incredible difficulty figuring out what was happening for her. Eventually it became clear that she was 34 weeks pregnant with a complete placenta previa (placenta implanted over the cervix). She had an antepartum hemorrhage. There were no doctors on site. There was no one in the lab to type and cross-match her blood. The midwife who eventually arrived was trying to call in a doctor and the lab so that we could get her to surgery. They took her off to surgery just before we left. By the time we were gone there was still no doctor. We found out this morning that they did a C/S (babe already dead), transfused her with two units of blood during and just after surgery with orders to transfuse her with two more units post-op. She died on the postpartum ward before they could give the second two units. This was her ninth pregnancy. According to her file she had three living children at home. What a loss. How challenging for the staff here, not to have doctors, anaethetists, lab personnel on site. It is a big blow to have a maternal death, especially at the referral hospital. Such sad news to arrive to today.
It was a much slower day today - two vaginal births, which Anne-Marie and Brynne managed. I attended a dilation and curettage for an incomplete miscarriage with Mickey. I also successfully sited two IVs today on my first go, which was encouraging. It was nice to leave a little early, when all was calm, and have a little time to post to the blog.
Waylaba (goodbye in Lugandan)
Heather
Sunday, June 24, 2007
A Weekend Away
Hello all...it's been a few days since my last post and I'm typing away on one of the slowest computers I've yet come across in Masaka, so I'm unsure as to how much I'll get written this evening.
To start from where I left off - a few more thoughts about visiting the TBAs:
-most of these women had learned their skills from their mothers or grandmothers; in fact there was a mother-daughter duo present at the workshop!
-each TBA attended between 2 and 5 births per month.
-despite having good skills and training, and knowledge about when they should refer women to a health centre or hospital, the lack of transport is a major risk factor when there is an emergency during a birth. As well, these women are not trained in, nor do they have access to, some of the basic medications and supplies we would use at a home birth in Canada. It was interesting to learn that some of them buy ergometrine of their own volition to use in the case of postpartum hemorrhage. The district health nurse-midwife who attended the workshop with us was trying to discourage the TBAs from using medications at the births they attend as they are not trained in the correct usage - it's not considered within their scope. As well, we expressed some concern that if they were going to be giving meds, ergometrine is not a good first line treatment for hemorrhage - oxytocin is a much better choice. I can understand the desire of the TBAs to have some other way to manage a postpartum hemorrage - I find it scary to think about attending a homebirth and not having any options for treating a hemorrhage. Add to that really sketchy transport situation and it certainly puts into perspective the work that these women do out in the rural areas of Uganda.
On Thursday we were back at Masaka Hospital. It was an interesting day, upsetting in some ways. Very slow in terms of births, in fact, the only term vaginal delivery occurred after Anne-Marie and I had left. But Brynne and Cathy were still there, which was great, as Brynne caught the first baby of a 15 year old woman who had a very traumatic labour. She was so young, and incredibly distressed throughout most of her labour. It was hard to know what was going on for her, she was requesting a C-section from the moment she arrived, and she spent a lot of time crying and screaming, both with contractions and in between. Again the language barrier was distressing. In the end though, she pushed her baby out with no complications, Brynne caught this little girl, over an intact perineum, despite directives from the Ugandan midwives to cut an episiotomy. I think we're gaining a reputation for prevention of tears - some of the Ugandan students (and even one of the interns) have been requesting to attend births with us so that they can learn how we manage second stage (the pushing stage).
We had a long weekend, taking Friday off. Cathy, Mickey, Brynne and family, and myself headed to Queen Elizabeth National Park to see some Ugandan wildlife. We met Cathy and Mickey's daughter-in-law Lindsey and her friend Andrea there. It was a great weekend. Cathy generously hired and payed for a vehicle and driver to take us from Masaka to QENP, where we stayed at the lovely Kingfisher Lodge just outside the park. We had a great mix of relaxation and exploration, spending some time at the lodge lounging, reading, enjoying the view. The kids played in the wading pool much of Saturday. We also saw lots of animals - elephants, hippos, crocodiles, antelope (Water Buck and Kob), lions, a leopard!, many birds, warthogs, mongoose (mongeese?), water buffalo...it was great. We took lots of pictures and just enjoyed the scenery and landscape. A real treat.
I'm feeling ready to head back to the hospital tomorrow. Cathy, Mickey, Anne-Marie, and I only have 3 days left here in Masaka. We head up to Kampala on Thursday morning to spend a day and half working on the high risk ward. Then Cathy and Mickey fly off to Zambia to meet Inna and Elaine. A-M and I will spend two more weeks working in the low-risk ward in Kampala while Brynne will remain with her family in Masaka and continue working at the hospital here. It will be a sad parting of ways but I'm looking forward to the change and hoping that we will get a few more births in Kampala as none of us have attended as many as anticipated yet and I would like to attend a good number more before I finish my placement here.
Well, time to post this entry. I'll write again soon. Sending love and light from Uganda to you all.
Heather
To start from where I left off - a few more thoughts about visiting the TBAs:
-most of these women had learned their skills from their mothers or grandmothers; in fact there was a mother-daughter duo present at the workshop!
-each TBA attended between 2 and 5 births per month.
-despite having good skills and training, and knowledge about when they should refer women to a health centre or hospital, the lack of transport is a major risk factor when there is an emergency during a birth. As well, these women are not trained in, nor do they have access to, some of the basic medications and supplies we would use at a home birth in Canada. It was interesting to learn that some of them buy ergometrine of their own volition to use in the case of postpartum hemorrhage. The district health nurse-midwife who attended the workshop with us was trying to discourage the TBAs from using medications at the births they attend as they are not trained in the correct usage - it's not considered within their scope. As well, we expressed some concern that if they were going to be giving meds, ergometrine is not a good first line treatment for hemorrhage - oxytocin is a much better choice. I can understand the desire of the TBAs to have some other way to manage a postpartum hemorrage - I find it scary to think about attending a homebirth and not having any options for treating a hemorrhage. Add to that really sketchy transport situation and it certainly puts into perspective the work that these women do out in the rural areas of Uganda.
On Thursday we were back at Masaka Hospital. It was an interesting day, upsetting in some ways. Very slow in terms of births, in fact, the only term vaginal delivery occurred after Anne-Marie and I had left. But Brynne and Cathy were still there, which was great, as Brynne caught the first baby of a 15 year old woman who had a very traumatic labour. She was so young, and incredibly distressed throughout most of her labour. It was hard to know what was going on for her, she was requesting a C-section from the moment she arrived, and she spent a lot of time crying and screaming, both with contractions and in between. Again the language barrier was distressing. In the end though, she pushed her baby out with no complications, Brynne caught this little girl, over an intact perineum, despite directives from the Ugandan midwives to cut an episiotomy. I think we're gaining a reputation for prevention of tears - some of the Ugandan students (and even one of the interns) have been requesting to attend births with us so that they can learn how we manage second stage (the pushing stage).
We had a long weekend, taking Friday off. Cathy, Mickey, Brynne and family, and myself headed to Queen Elizabeth National Park to see some Ugandan wildlife. We met Cathy and Mickey's daughter-in-law Lindsey and her friend Andrea there. It was a great weekend. Cathy generously hired and payed for a vehicle and driver to take us from Masaka to QENP, where we stayed at the lovely Kingfisher Lodge just outside the park. We had a great mix of relaxation and exploration, spending some time at the lodge lounging, reading, enjoying the view. The kids played in the wading pool much of Saturday. We also saw lots of animals - elephants, hippos, crocodiles, antelope (Water Buck and Kob), lions, a leopard!, many birds, warthogs, mongoose (mongeese?), water buffalo...it was great. We took lots of pictures and just enjoyed the scenery and landscape. A real treat.
I'm feeling ready to head back to the hospital tomorrow. Cathy, Mickey, Anne-Marie, and I only have 3 days left here in Masaka. We head up to Kampala on Thursday morning to spend a day and half working on the high risk ward. Then Cathy and Mickey fly off to Zambia to meet Inna and Elaine. A-M and I will spend two more weeks working in the low-risk ward in Kampala while Brynne will remain with her family in Masaka and continue working at the hospital here. It will be a sad parting of ways but I'm looking forward to the change and hoping that we will get a few more births in Kampala as none of us have attended as many as anticipated yet and I would like to attend a good number more before I finish my placement here.
Well, time to post this entry. I'll write again soon. Sending love and light from Uganda to you all.
Heather
Wednesday, June 20, 2007
Photo Frustration
Well, either my memory card reader has quit working properly or this is the second computer that is unable to read my card. Either way, I'm still unable to post any photos, which is unfortunate, because I have some lovely ones to put up. But I probably shouldn't be too grumpy about it, given that I'm pretty lucky to have relatively speedy internet service at all. So you shall have to be satisfied with my words and thoughts and use your own imagination to envision what we are seeing and the people we are meeting.
My mom posted a comment to my last entry regarding the flowering vine I was describing - she was right, it is bouganvillea. I remembered the name as I was sitting in the back of a landrover today, heading out into a rural area to meet with some Traditional Birth Attendants (TBAs) in Kalungu District. What a nice change of pace today was - we left Masaka mid-morning, after purchasing some supplies to donate to the TBAs and some bread, pb & jam, and sodas to share for lunch. We met the TBAs at a rural health centre, just a small outpost staffed by a couple of nurses. There were 9 TBAs who came from the surrounding area to spend the day with us. We met outside, under a huge jackfruit tree that was completely laden with fruit. It was a warm sunny day, but a strong breeze kept us cool. I kept glancing up, hoping that none of the jackfruit were ripe - you'd have a pretty sore head if one of those beasts landed on you!
We started our meeting by talking with the TBAs about their successes and challenges attending births. Most of these women have had some formal training, usually consisting of occasional courses taught by the local midwives or health educators. They are trained to manage normal births and trained to recognize what conditions or complications are beyond their scope of practice and thus require referral. One of the ladies, quite an old woman who estimated that she's been attending births for 40 years or so, told us a story about catching a footling breech baby. Many of the women described lack of adequate, reliable transport as one of their biggest challenges. The road is really rough - we bounced about in the landrover driving in there - huge ruts and potholes in the red-dirt road. We were told that in the rainy season it's impassable. Most people don't have their own vehicle. If a vehicle is found, the people don't have money for fuel to get to a hospital. It is a huge problem. Even the local midwife, whom we met with after our meeting with the TBAs, said that transport is her greatest worry because although an ambulance is often available, the woman's family has to pay for the fuel for transport. This midwife described begging the In-Charge of the Health Centre and the Sub-County Supervisor for money to transport women out in labour. Can you imagine calling an ambulance in Canada, having them show up at your door, and then ask for money for gas?
We talked with the TBAs about positions for giving birth - they did some demonstrations for us and then we reciprocated. There was much laughter all around. We also talked about reasons to refer women into the Health Centre or Hospital.
Oh dear, I'm already out of time. Seems that I'm underestimating how much I have to say. Until next time!
Heather
My mom posted a comment to my last entry regarding the flowering vine I was describing - she was right, it is bouganvillea. I remembered the name as I was sitting in the back of a landrover today, heading out into a rural area to meet with some Traditional Birth Attendants (TBAs) in Kalungu District. What a nice change of pace today was - we left Masaka mid-morning, after purchasing some supplies to donate to the TBAs and some bread, pb & jam, and sodas to share for lunch. We met the TBAs at a rural health centre, just a small outpost staffed by a couple of nurses. There were 9 TBAs who came from the surrounding area to spend the day with us. We met outside, under a huge jackfruit tree that was completely laden with fruit. It was a warm sunny day, but a strong breeze kept us cool. I kept glancing up, hoping that none of the jackfruit were ripe - you'd have a pretty sore head if one of those beasts landed on you!
We started our meeting by talking with the TBAs about their successes and challenges attending births. Most of these women have had some formal training, usually consisting of occasional courses taught by the local midwives or health educators. They are trained to manage normal births and trained to recognize what conditions or complications are beyond their scope of practice and thus require referral. One of the ladies, quite an old woman who estimated that she's been attending births for 40 years or so, told us a story about catching a footling breech baby. Many of the women described lack of adequate, reliable transport as one of their biggest challenges. The road is really rough - we bounced about in the landrover driving in there - huge ruts and potholes in the red-dirt road. We were told that in the rainy season it's impassable. Most people don't have their own vehicle. If a vehicle is found, the people don't have money for fuel to get to a hospital. It is a huge problem. Even the local midwife, whom we met with after our meeting with the TBAs, said that transport is her greatest worry because although an ambulance is often available, the woman's family has to pay for the fuel for transport. This midwife described begging the In-Charge of the Health Centre and the Sub-County Supervisor for money to transport women out in labour. Can you imagine calling an ambulance in Canada, having them show up at your door, and then ask for money for gas?
We talked with the TBAs about positions for giving birth - they did some demonstrations for us and then we reciprocated. There was much laughter all around. We also talked about reasons to refer women into the Health Centre or Hospital.
Oh dear, I'm already out of time. Seems that I'm underestimating how much I have to say. Until next time!
Heather
Tuesday, June 19, 2007
A beautiful walk
We are so lucky to have a beautiful walk each morning and evening as we make our way to and from Masaka Hospital. I took some pictures this morning with the intention of posting them but the computer that I'm sitting at this afternoon is not cooperating so you will have to wait for the photos to appear. We walk along a quiet road, for the most part paved, though there are many potholes. The few vehicles and boda-bodas (motorcycle taxis) swerve constantly as they try to avoid the worst of the holes. But really, there isn't much traffic on the road and much of it is lined with gigantic eucalyptus trees, their leaves swaying in the morning breeze. One of the fences we pass is covered with a flowering plant - the name escapes me at the moment but we definitely have these flowers as houseplants at home. We say "wasuzotia" to the Ugandan people we pass - a greeting that means, "how are you?". They respond with "Chendi" or "Burungi" - fine, good. The traffic is so hectic in Masaka town that it's a treat to have a quiet road to walk on as we head into a busy day at work.
Today the ward was quiet when we first arrived but by late morning the pace had sped up and it wasn't until 3:30pm that we had time for a breath and a break. Anne-Marie and I each caught a baby today. There were complications with both these births, though I think they were managed well. The woman A-M was attending was a gravida 9 (9th pregnancy) - the baby was born quickly but the placenta was retained. We used a fair bit of oxytocin to try to get the placenta out but after an hour, it was still in situ. She wasn't actively bleeding but we were quite worried that she might start to hemorrhage at any moment. Complicating the problem was a lack of normal saline on the ward. There were no bottles available. Someone had to go and beg pharmacy or the ER for a few extra bottles. Once we finally had the NS hung and running and it was apparent that the oxytocin was not effective, Cathy did a manual removal of the placenta. The woman was given demerol to help with the pain but it is an intense procedure. It was a difficult removal, the woman was in a lot of pain, pushing at Cathy with her foot. Anne-Marie and I tried as best we could to comfort her and restrain her so that Cathy could get the placenta out. She persevered and managed to remove it but we're quite certain that there are retained pieces as it did not look whole. We've left her on the ward for the night, with instructions to alert the nurses if she starts to bleed, and are hoping that she remains stable. It's so hard to know what will happen.
The woman I attended had active malaria. She was a first time mom - had a headache and fever when she presented at the hospital. A blood smear confirmed the malaria. Cathy warned us that the baby would probably need resuscitation as they can be affected by the maternal fever and perhaps the parasite crosses the placenta and infects the baby too - don't know about that - will have to ask the nurses on the ward on Thursday. The birth was a normal vaginal delivery with no tears or postpartum complications but the baby needed very active resuscitation and then had to go to the ER to have oxygen. I'm out of time, I will write more about this next I'm online. Overall, a fairly good day.
Ciao,
H
Today the ward was quiet when we first arrived but by late morning the pace had sped up and it wasn't until 3:30pm that we had time for a breath and a break. Anne-Marie and I each caught a baby today. There were complications with both these births, though I think they were managed well. The woman A-M was attending was a gravida 9 (9th pregnancy) - the baby was born quickly but the placenta was retained. We used a fair bit of oxytocin to try to get the placenta out but after an hour, it was still in situ. She wasn't actively bleeding but we were quite worried that she might start to hemorrhage at any moment. Complicating the problem was a lack of normal saline on the ward. There were no bottles available. Someone had to go and beg pharmacy or the ER for a few extra bottles. Once we finally had the NS hung and running and it was apparent that the oxytocin was not effective, Cathy did a manual removal of the placenta. The woman was given demerol to help with the pain but it is an intense procedure. It was a difficult removal, the woman was in a lot of pain, pushing at Cathy with her foot. Anne-Marie and I tried as best we could to comfort her and restrain her so that Cathy could get the placenta out. She persevered and managed to remove it but we're quite certain that there are retained pieces as it did not look whole. We've left her on the ward for the night, with instructions to alert the nurses if she starts to bleed, and are hoping that she remains stable. It's so hard to know what will happen.
The woman I attended had active malaria. She was a first time mom - had a headache and fever when she presented at the hospital. A blood smear confirmed the malaria. Cathy warned us that the baby would probably need resuscitation as they can be affected by the maternal fever and perhaps the parasite crosses the placenta and infects the baby too - don't know about that - will have to ask the nurses on the ward on Thursday. The birth was a normal vaginal delivery with no tears or postpartum complications but the baby needed very active resuscitation and then had to go to the ER to have oxygen. I'm out of time, I will write more about this next I'm online. Overall, a fairly good day.
Ciao,
H
Monday, June 18, 2007
Diving back in...
I woke up this morning with fear and trepidation beating a drum in synchrony in my stomach. I was nervous about returning to Masaka Hospital - worried about what we would encounter and my ability to respond to urgent concerns with grace and skill. As we walked along under the eucalyptus trees on the way to the hospital, I felt my anxiety grow and found myself a wee bit teary-eyed as we changed into our uniforms in the 'Sister's Room'. I knew that I needed to face these fears and anxieties, to just walk back into the labour and delivery room, take a breath, and be in the present moment, be with women, be calm, caring, and available for them. So that's what I did and it was okay. I did okay. We had a relatively good day, in terms of our management of cases. Two women went to C-section, one for failure to progress and the other for "CPD" - Cephalo-pelvic disproportion. The surgeon reported that both cases were managed well and he felt that both sections were appropriate. Moms and babes were healthy following both surgeries.
Anne-Marie caught her first Ugandan baby today! For various reasons, she had not yet been the primary midwife at a birth. A baby boy, born to a first-time mother who pushed for about 45 minutes but popped that babe out unexpectedly quickly at the end. The babe needed a little help getting going with his breathing - resuscitated by Cathy and Brynne - but was doing just fine after a few puffs with the bag and mask.
We had a second vaginal birth today, of a 23 week fetus that had died some time ago. It was distressing, but Cathy managed the birth with grace and skill and I think we all learned some important points regarding managing the birth of a macerated still-born babe. We were sure to have an IV line placed as hemorrhages are often associated with stillbirths and we wanted to prevent a major bleed. The mother did well, though it took about 15 minutes for the placenta to deliver. I think because the birth was so unexpected, the mother didn't have any cloths to wrap the babe in. Cathy had a wee cloth, stitched by Heather Wood many years ago when she and Cathy worked together in Saskatchewan, which we used to wrap up this tiny baby boy. When we left the ward this afternoon, this woman was doing well, with no unusual bleeding, stable vital signs - we felt really positive about how we managed the situation and hopefully she won't have any further complications. It's hard to know why this babe died, but Cathy thought perhaps the mother had contracted malaria in the pregnancy, which can cause fetal death.
Brynne, Anne-Marie, and I all successfully sited IV's today, a skill that continues to be somewhat nerve-wracking for me, though I am feeling better about my ability to do this following today's success. I have a goal of putting in at least one IV every day this week, more if they are available.
On Wednesday, we are heading out into a rural area for the day to meet with some Traditional Birth Attendants (TBAs). We will be bringing some supplies - boxes of gloves, soap, and small bottles of bleach, to give to each TBA. We're purchasing these supplies with some of the money collected by Anne-Marie and myself from our generous friends and families - it feels like a really worthwhile use of donated funds. These women attend many births in rural areas which are far from hospitals and health centres and are often the only people available to assist birthing women. Some of them have taken basic training courses. We will be talking with them about what normal birth looks like and when they should refer women to a hospital or health centre. For example, if the baby is in a transverse or breech presentation, if the woman has already had more than 5 babies, if she is very young (less than 18 years), if the labour is prolonged, if there is active bleeding, etc. It should be a fun day, with an opportunity to meet with the midwives at the rural health centre as well.
Must run as it's getting dark and it's time for me to head back to the Zebra.
With love and light,
H
Anne-Marie caught her first Ugandan baby today! For various reasons, she had not yet been the primary midwife at a birth. A baby boy, born to a first-time mother who pushed for about 45 minutes but popped that babe out unexpectedly quickly at the end. The babe needed a little help getting going with his breathing - resuscitated by Cathy and Brynne - but was doing just fine after a few puffs with the bag and mask.
We had a second vaginal birth today, of a 23 week fetus that had died some time ago. It was distressing, but Cathy managed the birth with grace and skill and I think we all learned some important points regarding managing the birth of a macerated still-born babe. We were sure to have an IV line placed as hemorrhages are often associated with stillbirths and we wanted to prevent a major bleed. The mother did well, though it took about 15 minutes for the placenta to deliver. I think because the birth was so unexpected, the mother didn't have any cloths to wrap the babe in. Cathy had a wee cloth, stitched by Heather Wood many years ago when she and Cathy worked together in Saskatchewan, which we used to wrap up this tiny baby boy. When we left the ward this afternoon, this woman was doing well, with no unusual bleeding, stable vital signs - we felt really positive about how we managed the situation and hopefully she won't have any further complications. It's hard to know why this babe died, but Cathy thought perhaps the mother had contracted malaria in the pregnancy, which can cause fetal death.
Brynne, Anne-Marie, and I all successfully sited IV's today, a skill that continues to be somewhat nerve-wracking for me, though I am feeling better about my ability to do this following today's success. I have a goal of putting in at least one IV every day this week, more if they are available.
On Wednesday, we are heading out into a rural area for the day to meet with some Traditional Birth Attendants (TBAs). We will be bringing some supplies - boxes of gloves, soap, and small bottles of bleach, to give to each TBA. We're purchasing these supplies with some of the money collected by Anne-Marie and myself from our generous friends and families - it feels like a really worthwhile use of donated funds. These women attend many births in rural areas which are far from hospitals and health centres and are often the only people available to assist birthing women. Some of them have taken basic training courses. We will be talking with them about what normal birth looks like and when they should refer women to a hospital or health centre. For example, if the baby is in a transverse or breech presentation, if the woman has already had more than 5 babies, if she is very young (less than 18 years), if the labour is prolonged, if there is active bleeding, etc. It should be a fun day, with an opportunity to meet with the midwives at the rural health centre as well.
Must run as it's getting dark and it's time for me to head back to the Zebra.
With love and light,
H
Sunday, June 17, 2007
My mantra...
"I am only one, but still I am one. I cannot do everything, but still I can do something; I will not refuse to do something I can do." Helen Keller.
Saturday, June 16, 2007
Time and space
It is Saturday morning, the sky is hazy with low clouds, the air is warm but not muggy, and my eyes are heavy with fatigue; my stomach grumbling, rolling over in protest over the two tomato slices I ate yesterday afternoon. It's been a slow morning, dozing in to 9:30am after a night of little sleep. I am sharing rooms with Brynne's family, the Purcell's, at the Hotel Zebra. Isa and Canaan, Brynne's daughters, and I are sleeping in the same room and last night found Canaan and I both awake intermittently, tossing about under our mosquito nets. My protesting stomach was not conducive to resting well, so I spent the night with pictures of Ugandan mama's rolling through my mind. Occasionally I'd slip into sleep, dreaming of women pushing out their babies, their voices calling out in pain and prayer, only to wake and find that Canaan was crying out in her restless sleep beside me.
On Thursday evening, Cathy and Mickey hosted a pizza party for us all at a cafe that supports a Ugandan/Danish NGO. Two of our Ugandan colleagues, Prossy and Teddy, joined us and we had good chats about Ugandan culture, language, HIV prevalence and treatment, and programs to reduce HIV transmission from mother to child. Prossy is a midwife and worked closely with Cathy and the UBC students last year - this year she is working with Uganda Cares, a government- and internationally-funded program that provides HIV testing, counseling, medication, and support to Ugandans. Prossy says that at the centre here in Masaka they see over 450 people per day. Despite Uganda having been quite successful in reducing the transmission of HIV, the need is still incredibly great. In the last year, HIV testing of pregnant women has become mandatory, so almost every woman who accesses antenatal care is tested, and if found to be positive, is counseled, given medication for the duration of her pregnancy, and provided with medication for her newborn babe to try and prevent vertical transmission between mama and babe. Women are counseled about feeding - if they can afford formula, they are encouraged to exclusively formula feed. If they can't afford artificial feeding, they are encouraged to exclusively breastfeed for 6 months and then to wean their babes and start them on solids. While there is a risk of HIV transmission through breastmilk, for women who can't afford proper formula and clean water, the risk of infant mortality due to gastrointestinal disease is higher than the risk of HIV transmission. It's been found that mixed feeding, breast and bottle, further increases the rate of transmission. So it's exclusive bottle or exclusive breast.
After dinner, Mickey, Cathy and I headed back to the hospital to do a second curettage on the woman whose babe was stillborn on Wednesday morning. Mickey had done a curettage Wednesday afternoon but an ultrasound on Thursday had shown there were still some retained products in her uterus. Given that she had been febrile and in shock the day before, he wanted to be sure that her uterus was completely empty to prevent reinfection or a late postpartum hemorrhage. We brought her into the labour and delivery room, where she placed her plastic sheet on this rickety half-size table and then climbed up, Cathy and I helping her to place her legs in the awkward stirrups which we couldn't adjust to make it more comfortable for her. Here in Masaka, they rarely have access to any sort of sedative or analgesia for these sorts of procedures, so the best we could offer was me holding her hand and shoulder, looking into her eyes, while Mickey inserted the speculum, grasped her cervix with ring forceps, and cleaned out her uterus with the curette. It was a quick procedure, less than five minutes probably, and she was so brave but cried out in pain several times. When it was over, we took her back to the postpartum ward where she was to receive another dose of flagyl and some more IV fluids through the night. Cathy spoke with her mother-in-law, through the nurse who translated, telling her how brave this young woman had been through the very painful procedures to save her life. Perhaps this will make a difference as to how her family treats her and views her when she goes home, perhaps not. It's hard to know. She's most likely back in her village now - I wonder if she's back to work or will be able to rest for a couple more days before resuming her responsibilities?
We spent a half day at the hospital yesterday morning. Cathy and Mickey headed to Kampala as they had to pick up some paperwork. So it was Brynne, Anne-Marie, and I alone on the labour and delivery ward. It was a quiet morning, one woman being prepped for C/S, another woman in active labour, another waiting for a curettage procedure following an incomplete miscarriage, and a fourth who came in for labour assessment. We had seen this woman in the early labour ward the day before, though none of us had examined her. Brynne started the assessment, finding her at about 4 cm dilated with fairly regular contractions. But she was unable to find the fetal heart. Her chart said that the fetal heart had been heard that morning, around 5am, but none of us could find it, nor could the in-charge midwife Teddy, nor could Doctor Doreen who came in to assess. As it was a week-day, we were able to send her to ultrasound for a scan. The scan found that her babe was dead, and in fact probably had been for some time, given the amount of moulding of the skull, something that apparently happens once a fetus dies. The ultrasonographer told us that there was no way the fetal heart could have been heard that morning, which left us wondering whether it was truly heard the day before when she was on the ward being monitored. Though it can be difficult with pinard fetoscopes, it is awful to think that whoever was assessing her wasn't really listening thoroughly and that her babe had been dead since she'd come in. The doctor ordered an oxytocin drip to speed up her labour and Brynne attended as a second, not catching the baby but holding this woman's hand as she birthed her stillborn babe. Another sad morning, with no apparent cause for this fetal death, except the late realization that her membranes were already ruptured so perhaps there had been an infection. It's so hard to know.
My time is short...I will post again soon. Thanks to all who have posted notes of support and love. We so appreciate knowing that people are reading our blog and steppinginto Ugandan maternity care through our words.
With love,
Heather
On Thursday evening, Cathy and Mickey hosted a pizza party for us all at a cafe that supports a Ugandan/Danish NGO. Two of our Ugandan colleagues, Prossy and Teddy, joined us and we had good chats about Ugandan culture, language, HIV prevalence and treatment, and programs to reduce HIV transmission from mother to child. Prossy is a midwife and worked closely with Cathy and the UBC students last year - this year she is working with Uganda Cares, a government- and internationally-funded program that provides HIV testing, counseling, medication, and support to Ugandans. Prossy says that at the centre here in Masaka they see over 450 people per day. Despite Uganda having been quite successful in reducing the transmission of HIV, the need is still incredibly great. In the last year, HIV testing of pregnant women has become mandatory, so almost every woman who accesses antenatal care is tested, and if found to be positive, is counseled, given medication for the duration of her pregnancy, and provided with medication for her newborn babe to try and prevent vertical transmission between mama and babe. Women are counseled about feeding - if they can afford formula, they are encouraged to exclusively formula feed. If they can't afford artificial feeding, they are encouraged to exclusively breastfeed for 6 months and then to wean their babes and start them on solids. While there is a risk of HIV transmission through breastmilk, for women who can't afford proper formula and clean water, the risk of infant mortality due to gastrointestinal disease is higher than the risk of HIV transmission. It's been found that mixed feeding, breast and bottle, further increases the rate of transmission. So it's exclusive bottle or exclusive breast.
After dinner, Mickey, Cathy and I headed back to the hospital to do a second curettage on the woman whose babe was stillborn on Wednesday morning. Mickey had done a curettage Wednesday afternoon but an ultrasound on Thursday had shown there were still some retained products in her uterus. Given that she had been febrile and in shock the day before, he wanted to be sure that her uterus was completely empty to prevent reinfection or a late postpartum hemorrhage. We brought her into the labour and delivery room, where she placed her plastic sheet on this rickety half-size table and then climbed up, Cathy and I helping her to place her legs in the awkward stirrups which we couldn't adjust to make it more comfortable for her. Here in Masaka, they rarely have access to any sort of sedative or analgesia for these sorts of procedures, so the best we could offer was me holding her hand and shoulder, looking into her eyes, while Mickey inserted the speculum, grasped her cervix with ring forceps, and cleaned out her uterus with the curette. It was a quick procedure, less than five minutes probably, and she was so brave but cried out in pain several times. When it was over, we took her back to the postpartum ward where she was to receive another dose of flagyl and some more IV fluids through the night. Cathy spoke with her mother-in-law, through the nurse who translated, telling her how brave this young woman had been through the very painful procedures to save her life. Perhaps this will make a difference as to how her family treats her and views her when she goes home, perhaps not. It's hard to know. She's most likely back in her village now - I wonder if she's back to work or will be able to rest for a couple more days before resuming her responsibilities?
We spent a half day at the hospital yesterday morning. Cathy and Mickey headed to Kampala as they had to pick up some paperwork. So it was Brynne, Anne-Marie, and I alone on the labour and delivery ward. It was a quiet morning, one woman being prepped for C/S, another woman in active labour, another waiting for a curettage procedure following an incomplete miscarriage, and a fourth who came in for labour assessment. We had seen this woman in the early labour ward the day before, though none of us had examined her. Brynne started the assessment, finding her at about 4 cm dilated with fairly regular contractions. But she was unable to find the fetal heart. Her chart said that the fetal heart had been heard that morning, around 5am, but none of us could find it, nor could the in-charge midwife Teddy, nor could Doctor Doreen who came in to assess. As it was a week-day, we were able to send her to ultrasound for a scan. The scan found that her babe was dead, and in fact probably had been for some time, given the amount of moulding of the skull, something that apparently happens once a fetus dies. The ultrasonographer told us that there was no way the fetal heart could have been heard that morning, which left us wondering whether it was truly heard the day before when she was on the ward being monitored. Though it can be difficult with pinard fetoscopes, it is awful to think that whoever was assessing her wasn't really listening thoroughly and that her babe had been dead since she'd come in. The doctor ordered an oxytocin drip to speed up her labour and Brynne attended as a second, not catching the baby but holding this woman's hand as she birthed her stillborn babe. Another sad morning, with no apparent cause for this fetal death, except the late realization that her membranes were already ruptured so perhaps there had been an infection. It's so hard to know.
My time is short...I will post again soon. Thanks to all who have posted notes of support and love. We so appreciate knowing that people are reading our blog and steppinginto Ugandan maternity care through our words.
With love,
Heather
Thursday, June 14, 2007
Overwhelmed and overstretched...
It is Thursday morning and I'm quickly posting to the blog before heading to the hospital for the day. We are going in a wee bit later today, partly because Cathy has some admin work she needs to do and partly because the last two days were intense and having a later start seemed like a wise idea.
Two days ago we lost a mother - the woman's seventh pregnancy. She had taken some herbs in the village to stimulate her labour. When she came into hospital, at 9 cm dilated, her uterus was ruptured. The babe was already gone. She was taken to surgery but she had lost litres of blood and continued to lose more during the surgery. Anne-Marie observed and assisted at the surgery, so perhaps she'll want to write more about it. In the end, she had a hysterectomy but she had lost too much blood and she died shortly afterwards, leaving six children at home with no mother.
Yesterday morning, the first birth of the day for me, I caught a stillborn babe. This wee one had been dead for some time - we could tell because of the very strong smell and strange colour. The mother was infected we think, because her membranes had been ruptured for some time, but she also has a very narrow pelvis as the head was incredibly molded, far more so than would be normal for a live baby. This was the third baby she'd lost, the other two dying at one day of age. She is only 21 years old. Her cry as she realized that her baby was dead was heart-wrenching - her face keeps flashing through my mind's eye and I find myself welling up with tears at intervals as I think of her situation. She was berated by her mother-in-law for losing another baby. What will happen to her? Mickey (Cathy's husband, a family doc) had to do a D&C for her late in the afternoon as her uterus wasn't remaining contracted very well and she was shocky and feverish. I hope she isn't septic. He said there was a fair amount of retained tissue in her uterus.
I am feeling so angry at the discrepancies in care between the developed and developing world. I've always known that life isn't fair, but this just seems criminal. There just aren't the resources for women in rural areas to receive proper antenatal care, for transport to larger centres when things go wrong, for basic supplies like gloves and razor blades, antibiotics. Oh, it's just so hard. And so difficult to not speak Lugandan and thus not be able to really support women well, to speak with them in their own language, to celebrate with them and grieve with them. I am so frustrated with myself when I can't communicate a simple message to a mama.
Must go. We did have two lovely normal births yesterday - two primips, no tears, both very happy with their first-born babes. I also got to feel a breech presentation and a face presentation, both of which went to C/S, with live babes and healthy moms at the end. We visited a 97 year old Traditional Birth Attendant yesterday afternoon, who still delivers about 10 babies a month, despite having broken her leg 7 months ago. She was wonderful. I will post a picture when I next have time.
Two days ago we lost a mother - the woman's seventh pregnancy. She had taken some herbs in the village to stimulate her labour. When she came into hospital, at 9 cm dilated, her uterus was ruptured. The babe was already gone. She was taken to surgery but she had lost litres of blood and continued to lose more during the surgery. Anne-Marie observed and assisted at the surgery, so perhaps she'll want to write more about it. In the end, she had a hysterectomy but she had lost too much blood and she died shortly afterwards, leaving six children at home with no mother.
Yesterday morning, the first birth of the day for me, I caught a stillborn babe. This wee one had been dead for some time - we could tell because of the very strong smell and strange colour. The mother was infected we think, because her membranes had been ruptured for some time, but she also has a very narrow pelvis as the head was incredibly molded, far more so than would be normal for a live baby. This was the third baby she'd lost, the other two dying at one day of age. She is only 21 years old. Her cry as she realized that her baby was dead was heart-wrenching - her face keeps flashing through my mind's eye and I find myself welling up with tears at intervals as I think of her situation. She was berated by her mother-in-law for losing another baby. What will happen to her? Mickey (Cathy's husband, a family doc) had to do a D&C for her late in the afternoon as her uterus wasn't remaining contracted very well and she was shocky and feverish. I hope she isn't septic. He said there was a fair amount of retained tissue in her uterus.
I am feeling so angry at the discrepancies in care between the developed and developing world. I've always known that life isn't fair, but this just seems criminal. There just aren't the resources for women in rural areas to receive proper antenatal care, for transport to larger centres when things go wrong, for basic supplies like gloves and razor blades, antibiotics. Oh, it's just so hard. And so difficult to not speak Lugandan and thus not be able to really support women well, to speak with them in their own language, to celebrate with them and grieve with them. I am so frustrated with myself when I can't communicate a simple message to a mama.
Must go. We did have two lovely normal births yesterday - two primips, no tears, both very happy with their first-born babes. I also got to feel a breech presentation and a face presentation, both of which went to C/S, with live babes and healthy moms at the end. We visited a 97 year old Traditional Birth Attendant yesterday afternoon, who still delivers about 10 babies a month, despite having broken her leg 7 months ago. She was wonderful. I will post a picture when I next have time.
Tuesday, June 12, 2007
Some photos...
src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgD77GGacnV1zP7yyTBM9K1H42j5ep_uXKV0Oz4yOjfROOada9pL44zCr-f6Ua8oq-6_E6NtMrwCZMD6ZrnG-9fAV6d8EelMxPlYPLUxptyptGROT94zYlOqXmoa4YcRULA1rZOquDBGzc/s200/IMG_0597.JPG" border="0" alt=""id="BLOGGER_PHOTO_ID_5075189791785317170" />Anne-Marie and I in our whites - first day at Mulago Hospital in Kampala.
The second Ugandan baby I caught.
Buttress roots on a fig tree in Mpanga forest.
Today was a busy day at Masaka Hospital. Brynne attended two births, one of which was a total surprise - she was preparing to do a vaginal exam, pulled back the sheet, and there was the head! She caught that baby all by herself as Cathy had just left the room. I came in to find Brynne totally managing things while about 6 Ugandan nursing students stood about the bed watching her in action. She's a star! It seems that many of the Ugandan mothers who have had babies before have very very fast pushing stages. Chloe and Aisia, the students who were here last year, told us never to turn our backs on a Ugandan mother pushing - it's become very evident why that is!
Brynne's second birth was another multip (had at least one baby already)who arrived at the hospital already pushing. That baby had a very tight nuchal cord so Brynne somersaulted him out, just beautifully. It's just so lovely to be able to work with my classmates, to observe them managing births - we never get to see that at home because we're all in our separate placements. What fun to work together catching these babies. And how great to see what great midwives my friends and colleagues are already!
I caught a baby of a first time Mama today as well. She had what the Ugandan students thought was a very long pushing stage (35 minutes) - they were quite surprised that we weren't telling her to push harder, push longer. But we managed things in a Canadian way and it became clear with the birth of the head why things were moving "slowly" - there was a nuchal hand and cord, meaning one of babe's hands was up by her head and the cord was around the neck. It was a little challenging getting the shoulders out with that hand there, so we ended up getting her to move onto hands and knees (sort of, she really didn't understand what we wanted her to do) - then out came the shoulders and the babe with no trouble. And, no perineal tear, which I was very happy with, given she was a first-time mom with that little hand waving at us.
We are finally getting our accommodation sorted here in Masaka - it will be good to unpack for a while and feel like we're not always living out of suitcases. It was a beautiful day today, warm but breezy - a lovely summer temperature though a little more humid than the west coast of BC. We're back to the hospital again tomorrow and I'm so looking forward to it. I so love attending births - what a joy to be here, despite the lack of supplies and the challenges with language. We are slowly getting some key phrases and words, but there's so much more to learn. So far we can tell women to 'push', 'don't push', 'boy', 'girl', 'good morning', 'thank you', congratulations'. It's coming, but our communication is very dependent on the Ugandan students - luckily they are eager and happy to work with us, which is great.
Monday, June 11, 2007
This Is Africa
I am writing this post from an internet cafe in Masaka, having arrived in this town last night. Where to start...it seems that the days are so full and that so much has happened since we've arrived. It's somewhat inconceivable that we've only been in Uganda for 5 days. It feels as though weeks have passed, as though I've been exploring this country, meeting people here, adventuring in the countryside, for weeks, not days.
Anne-Marie, Brynne, and I spent half a day at Mulago Hospital on Saturday morning before leaving Kampala. It was a busy morning. Brynne attended one birth somewhat unexpectedly - walking into the assessment room to find a woman pushing her baby out with one of the Ugandan midwives in attendance. Anne-Marie and I managed another birth - my first catch here in Uganda. The babe was born in the caul and I had to break the bag of waters once her head was born. Anne-Marie gave the oxytocin and tied off the cord with glove cuffs and cut the cord. I serendipitously caught another baby that morning, walking into the assessment room only to have a midwife tell me to get my gloves on because the baby was coming. I looked over to see a head emerging, so quickly jumped to the bedside and caught the babe. It seems that midwives generally handle babies quite a bit differently, perhaps more roughly, than we do in Canada. This is hard to see and I look forward to the time when we're managing births more independently so that some babes have a gentler welcome into the world. It has been so interesting chatting with midwives about the differences in maternity care between Canada and Uganda - men almost never attend deliveries here in Uganda and they think it's very strange that most husbands/fathers/partners attend their babies' births in Canada. One midwife asked me if Canadian women feel pain in labour. She had heard that women in North America don't feel pain because they have medicine to take the pain away. So we had an interesting discussion about epidurals, the benefits, the risks.
After leaving Kampala on Saturday afternoon, we headed to Mpango Forest Reserve, about 40 km southwest of Kampala. We had a bus full of 10 people - Brynne and her family, Anne-Marie and her friend Nat, Lindsay (Cathy's daughter-in-law) and her friend Andrea, and myself. Plus ALL our luggage which includes masses of supplies. It was a cozy trip. Mpango was a wonderful oasis, away from the busy chaos of Kampala. We walked in the jungle, admired huge fig and mahogany trees, glimpsed monkeys, shook nasty biting ants off our pants and ankles, ate dinner around a campfire, played frisbee with some local kids, admired birds and termite mounds. It was quiet and green and lush and I loved it.
Today we had a tour of the Masaka hospital where we'll be working. The grounds of the hospital are beautiful and I'm looking forward to working in the maternity ward. We will also have the opportunity to work in the antenatal and family planning clinics. We're not yet sure how many births there will be daily, perhaps not as many as last year when Aisia and Chloe were here, but I'm sure there will be so many learning opportunities - we're not really concerned. We presented the administrator and senior doctor of the hospital with two of the eight birth kits that we are donating to the hospital. They are very pleased and are looking forward to receiving the rest of our donations, which include medications, IV needles, syringes, and many other things. Thanks again to everyone who contributed to these supplies - we can see how very appreciated they will be here. Tomorrow we head to the hospital for a full day on the ward - I'm excited to meet all the midwives and women and integrate into the system here.
I'm quickly running out of time. There is so much to say and never enough time. I hope that either Brynne or Anne-Marie will write the next post so that you'll have another perspective. We'll also try to get some pictures up soon.
Sending greetings to you all from Masaka.
Anne-Marie, Brynne, and I spent half a day at Mulago Hospital on Saturday morning before leaving Kampala. It was a busy morning. Brynne attended one birth somewhat unexpectedly - walking into the assessment room to find a woman pushing her baby out with one of the Ugandan midwives in attendance. Anne-Marie and I managed another birth - my first catch here in Uganda. The babe was born in the caul and I had to break the bag of waters once her head was born. Anne-Marie gave the oxytocin and tied off the cord with glove cuffs and cut the cord. I serendipitously caught another baby that morning, walking into the assessment room only to have a midwife tell me to get my gloves on because the baby was coming. I looked over to see a head emerging, so quickly jumped to the bedside and caught the babe. It seems that midwives generally handle babies quite a bit differently, perhaps more roughly, than we do in Canada. This is hard to see and I look forward to the time when we're managing births more independently so that some babes have a gentler welcome into the world. It has been so interesting chatting with midwives about the differences in maternity care between Canada and Uganda - men almost never attend deliveries here in Uganda and they think it's very strange that most husbands/fathers/partners attend their babies' births in Canada. One midwife asked me if Canadian women feel pain in labour. She had heard that women in North America don't feel pain because they have medicine to take the pain away. So we had an interesting discussion about epidurals, the benefits, the risks.
After leaving Kampala on Saturday afternoon, we headed to Mpango Forest Reserve, about 40 km southwest of Kampala. We had a bus full of 10 people - Brynne and her family, Anne-Marie and her friend Nat, Lindsay (Cathy's daughter-in-law) and her friend Andrea, and myself. Plus ALL our luggage which includes masses of supplies. It was a cozy trip. Mpango was a wonderful oasis, away from the busy chaos of Kampala. We walked in the jungle, admired huge fig and mahogany trees, glimpsed monkeys, shook nasty biting ants off our pants and ankles, ate dinner around a campfire, played frisbee with some local kids, admired birds and termite mounds. It was quiet and green and lush and I loved it.
Today we had a tour of the Masaka hospital where we'll be working. The grounds of the hospital are beautiful and I'm looking forward to working in the maternity ward. We will also have the opportunity to work in the antenatal and family planning clinics. We're not yet sure how many births there will be daily, perhaps not as many as last year when Aisia and Chloe were here, but I'm sure there will be so many learning opportunities - we're not really concerned. We presented the administrator and senior doctor of the hospital with two of the eight birth kits that we are donating to the hospital. They are very pleased and are looking forward to receiving the rest of our donations, which include medications, IV needles, syringes, and many other things. Thanks again to everyone who contributed to these supplies - we can see how very appreciated they will be here. Tomorrow we head to the hospital for a full day on the ward - I'm excited to meet all the midwives and women and integrate into the system here.
I'm quickly running out of time. There is so much to say and never enough time. I hope that either Brynne or Anne-Marie will write the next post so that you'll have another perspective. We'll also try to get some pictures up soon.
Sending greetings to you all from Masaka.
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